HOW    SO  DIAGNOSE 
SMALLPOX 


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HOW   TO    DIAGNOSE   SMALLPOX 


HOW   TO    DIAGNOSE 
SMALLPOX 

A  GUIDE  FOR  GENERAL  PRACTITIONERS 

POST-GRADUATE  STUDENTS 

AND   OTHERS 


BY 

W.    McC.    WANKLYN 

B.A.   Cantab.,   M.R.C.S.,   L.R.C.P.,   D.P.H. 

ASSISTANT  MEDICAL  OFFICER  OF  THE  LONDON  COUNTY  COUNCIL, 

AND   FORMERLY  MEDICAL  SUPERINTENDENT  OF  THE 

RIVER   AMBULANCE   SERVICE  (SMALLPOX)   OF 

THE  METROPOLITAN  ASYLUMS   BOARD 


WITH    ILLUSTRATIONS 


PAUL    B.    HOEBER 

69  EAST  59  ST. 

NEW  YORK 

1914 


PRINTED   BY 

WILLIAM   CLOWES   AND   SONS,    LIMITED 

LONDON   AND   BECCLES 


M\w.L\e 


HEALTH        / 
V  LIBRARY 


PEEFACE 


Delay  in  the  recognition  of  smallpox  is  an  im- 
portant factor  in  its  spread.  To  contribute  to  its 
earlier  recognition  is  the  object  of  this  book. 

It  treats  of  the  diagnosis  of  smallpox  as  a  matter 
vital  to  the  control  of  the  disease,  and  sets  out 
the  principal  diagnostic  points  in  handy  form,  so 
as  to  be  readily  available  in  practice.  Drafted 
eight  or  nine  years  ago,  in  the  form  of  notes  for 
post-graduate  demonstrations  or  lectures,  it  is 
intended  primarily  as  a  guide  for  those  who  are  in 
general  practice;  others,  however,  who  have  to 
deal  with  smallpox,  may  also  find  it  useful. 

Its  subject  matter  is  briefly  as  follows : 
the  effect  of  unrecognised  cases  in  spreading 
smallpox  ;  methods  of  clinical  examination  ; 
a  description  of  typical  cases  of  smallpox,  with 
special  reference  to  the  arrangement  of  the  rash 
upon  the  skin;  an  explanation  of  the  principle 
underlying   that    arrangement ;     other    diagnostic 

a  2 

845 


vi  PREFACE 

features  of  smallpox ;  the  initial  rashes ;  the 
differential  diagnosis  of  chickenpox,  measles,  and 
other  exanthems. 

The  aim  of  the  book  is  to  warn  the  diagnos- 
tician of  the  difficulties  and  traps  which  he  is  likely 
to  meet ;  how  to  avoid  them ;  to  assist  him  not 
merely  to  a  rough  proficiency,  but  to  a  high 
degree  of  accuracy  in  diagnosis.  It  is  the  author's 
belief  that  the  data  for  a  correct  diagnosis  are 
present  and  available  in  nearly  every  case  of 
smallpox;  and  that  accuracy  in  their  interpreta- 
tion may  be  attained,  with  even  a  moderate  amount 
of  practice,  if  due  attention  be  given  to  the  methods 
here  indicated. 

The  book  is  based  upon  an  acquaintance  with 
smallpox  extending  over  20  years,  and  including 
the  reception  of  the  cases  in  the  epidemic  of 
1901  and  1902,  during  which  years  it  fell  to  the 
writer  to  receive  from  London  about  10,000  cases 
certified  as  smallpox,  and  to  revise  their  original 
diagnoses. 

I  am  glad  of  this  opportunity  of  acknow- 
ledging my  indebtedness  to  my  former  teacher 
and  colleague,  Dr.  T.  F.  Bicketts ;  especially  as 
an  earlier  contribution  escaped  me,  to  my  regret, 


PREFACE  vii 

without  such  acknowledgment.  That  contribu- 
tion, and  these  pages,  are  little  more  than 
attempts  to  set  out  his  teaching  as  it  has  been 
put  into  practice  by  myself. 

My  thanks  are  also  given  to  those  who  have 
helped  me  in  the  preparation  of  this  book ; 
especially  to  my  former  colleague,  Dr.  A.  F. 
Cameron. 


London, 

May,  1913. 


CONTENTS 

CHAPTER  PAGE 

I.  The  Speead  of  Smallpox  by  Unrecognised 

Cases 1 

II.    Unrecognised  Cases  and  their  Remedy  .        .       10 

III.  Practical     Points      in      the      Method      op 

Examination 19 

IV.  Individual    Cases     op    Smallpox    considered 

with  a  View  to  Diagnosis     ....       26 

V.     Individual   Cases.     Other  Features  op  the 

Kash 36 

VI.     The     Explanation    op    the    Distribution    op 

the  Kash 44 

VII.     Other  Factors  in  Diagnosis      ....      55 

VIII.     Differential  Diagnosis 62 

IX.    The  Initial  Rashes 72 

X.     Differential    Diagnosis    of   Chickenpox    and 

of  Measles 85 

XI.    Additional  Points 97 

Index 103 


LIST   OF   ILLUSTRATIONS 


PLATES  TO  PACE  PAGE 

I.-IV.  Smallpox 54 

V.-VI.  Chickenpox 96 


Chart.  Prevalence  of  Smallpox  in  London  between 

1885  and  1912 18 

DIAGRAMS 

I.-III.     Petechial  Initial  Eash  of  Smallpox     .        .      84 
IV.    Dusky  Erythema  and  Hemorrhagic  Smallpox      84 


HOW     TO    DIAGNOSE 
SMALLPOX 

CHAPTER  I 

THE   SPREAD   OF   SMALLPOX   BY   UNRECOGNISED 
CASES 

It  is  essential  to  realise  the  mischief  which  may  be 
done  by  unrecognised  cases  of  smallpox.  There 
is  hardly  any  disease  of  which  the  prompt  recog- 
nition is  more  important  to  the  general  com- 
munity. Almost  every  outbreak  in  London  in 
recent  years  has  been  started,  or  propagated  and 
prolonged,  by  unrecognised  cases.  Epidemics  teem 
with  examples,  which  only  cease  to  be  recorded 
because  they  become  trite.  For  instance,  in  1888, 
Dr.  Birdwood,  then  Medical  Superintendent  of 
the  Smallpox  Hospitals  of  the  Metropolitan 
Asylums  Board,  reported :  "  The  other  lesson 
seems  to  be  that  greater  care  should  be  taken  in 
distinguishing    mild    attacks    of    smallpox    from 


2  HOW  TO  DIAGNOSE   SMALLPOX       [ch.  i 

chickenpox.  It  so  frequently  happens  that  the 
bedfellow  of  a  confluent  smallpox  patient  had 
previously  a  few  spots  that  had  been  mistaken 
for  chickenpox.  There  is  only  one  way  of  putting 
this  right — the  medical  profession  should  have 
opportunities  for  clinical  observation  placed  at 
their  disposal;  your  hospitals  alone  are  available 
for  that  purpose,  I  see  no  difficulties  in  the  way 
of  admitting  students  to  the  practice  of  this  hospital. 
They  ought  to  be  admitted  in  the  interests  of  the 
public  health."  Of  the  year  1892,  Dr.  Ricketts, 
who  succeeded  Dr.  Birdwood,  wrote,  "Early  in 
March,  smallpox  broke  out  in  a  crowded  locality 
in  Shoreditch.  The  source  of  infection  in  this 
instance  was  a  child  who  fell  ill  about  7th 
February,  her  complaint  being  diagnosed  as 
chickenpox.  It  is  not  known  how  she  contracted 
the  disease,  but  it  spread  from  her  to  other  inmates 
of  the  same  house,  and  thence  rapidly  to  the  sur- 
rounding population."  Of  the  epidemic  of  1893, 
Dr.  Long,  one  of  the  medical  officers  engaged, 
reported  that  thirty-one  persons  attributed  their 
attacks  of  smallpox  to  twenty-eight  cases  of 
"  chickenpox."  "  Two  of  the  local  outbreaks,"  he 
proceeds,   "are    to  be    ascribed  to   'chickenpox.' 


:h.  i] 


UNRECOGNISED   CASES 


Thirty-four  persons  ascribed  their  attacks  to  at 
least  thirty-four  cases  of  '  spots ' ;  fourteen  others 
to  various  complaints,  such  as  measles  com- 
plicated or  not  with  spots,  or  chickenpox, 
influenza  with  or  without  spots,  German  measles, 
or  some  slight  ailment.  Some  of  these  diagnoses 
were  made  by  chemists  and  other  irresponsible 
persons." 

In  his  report  for  the  year  1894,  Dr.  Ricketts 
quoted  this  case — 


A  young  man  had  influenza  •  with  spots.' 


He  fell  ill  about 
January  16th. 

I 
E.  B.'s  brother  living 
in  same  house  fell 
ill  with  "  chicken- 
pox  "  about  30th 
January. 
I 


He  returned  to  work  about  23rd  January 


Fellow  workman  of  above  fell  ill  with  "  chickenpox 
about  6th  February. 


E.  B., 

smallpox 
rash  ap- 
peared 
20th  Feb- 
ruary. 


A.  C, 

smallpox 
rash  ap- 
peared 
20th  Feb- 
ruary. 


H.  W.'s 

brother 
died  at 
home  of 
smallpox. 


H.  W., 

smallpox 
rash  ap- 
peared 
February 
19th. 


E.  L., 

smallpox 
rash  ap- 
peared 
February 
19th. 


A., 

smallpox 
rash  ap- 
peared 
February 
20th. 


A.T., 

smallpox 
rash  ap- 
peared 
February 
22nd. 


Both  of  these  patients 
lived  in  the  same 
house  as  the  above, 
and  were  removed 
to  hospital. 


The  last  five  of  these  cases  were  removed  to  hospital. 
With  the  exception  of  A.  T.,  all  came  from  the  same 
house  as  the  "  fellow  workman."  A.  T.  had  visited 
this  house  a  fortnight  before  her  rash  appeared. 


Again :  "Of  the  six  patients  mentioned 
(another  group  in  the  same  year,  1894),  two 
had  been  ill  with  smallpox  for  close  on  a  fortnight 
before  admission,  and  had  been  previously  treated 


4  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  i 

for  measles.  Another  person  in  the  house  had 
been  ill,  and  treated  for  three  weeks  for  chicken- 
pox,  while  the  fourth  had  an  illness  accompanied 
by  an  eruption  which  was  supposed  to  be  due 
to  blood-poisoning.  Supposing,  as  is  probable, 
these  persons  really  suffered  from  smallpox,  the 
group  of  cases  in  this  house  may  be  tabulated 
as  follows : — 

Mr.  F., 

Fell  ill  in  the  middle  of  December  with  blood-poisoning,  accompanied 

by  an  eruption  of  spots.    He  was  not  removed  from  home. 

Mrs.  G., 
Fell  ill  with  chickenpox  at  the  end  of  December,  and  was  in  bed  three 
weeks.    She  was  not  removed  from  home. 


A.  M., 
smallpox  rash  ap- 
peared 1st  February, 
admitted  to  hospital 
13th  February.    Pre- 
viously treated  for 
measles. 


W.  M., 

smallpox  rash  ap- 
peared 1st  February, 
admitted  to  hospital 
13th  February.    Pre- 
viously treated  for 
measles. 

-"1 


C.  G., 

smallpox  rash  ap- 
peared 9th  February. 


W.  M., 

smallpox  rash  ap- 
peared 22nd  Feb- 
ruary. 


E.  M., 

smallpox  rash  ap- 
peared 25th  Feb- 
ruary. 


W.  B., 

smallpox  rash  ap- 
peared 26th  Feb- 
ruary. 


Such  instances  as  the  foregoing  could  be 
multiplied  to  fill  a  volume.  I  will  give  two 
further  examples.  That  which  relates  to  the  year 
1900  is  a   very  remarkable  series   of    cases,   but 


ch.  i]  UNRECOGNISED   CASES  5 

led,  however,  to  no  great  outbreak.  There  were 
sixty-four  cases  of  smallpox  altogether  in  this 
year. 

Dr.  Ricketts  reported:  "A  group  of  cases 
occurred  in  Hackney  in  January  and  February, 
1900,  which  was  traced  to  a  gathering  of  friends 
in  a  small  house  in  Homerton,  on  Christmas 
Day,  1899.  It  was  found  afterwards  that  a  boy 
then  present  was  suffering  from  a  mild  attack  of 
smallpox.  His  illness  had  been  mistaken  for 
chickenpox.  Eight  persons  present  on  that 
occasion  afterwards  fell  ill  of  smallpox,  and 
seventeen  persons  in  all  owed  their  illness  to  the 
same  source. 

"  On  March  29th,  the  s.s.  Caledonia  arrived  in 
the  port  of  London.  The  steward  and  the  ship's 
clerk  returned  to  their  homes  in  St.  Pancras  and 
St.  Marylebone,  and  fell  ill  of  smallpox  within  a 
few  days  of  one  another.  Five  persons  with  whom 
they  came  in  contact  afterwards  developed  the 
disease. 

On  May  21st,  a  woman  was  admitted  here  with 
smallpox,  who  was  the  widow  of  a  valet  employed 
in  Victoria  Street,  Westminster.  Her  husband 
had  just   died,  it  was  supposed  of  measles ;  but 


6  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  i 

there  can  be  little  doubt  that  the  nature  of  the 
disease  was  hemorrhagic  smallpox.  The  origin  of 
his  illness  was  for  long  obscure,  but  it  appeared 
probable  that  he  caught  smallpox  at  an  eating- 
house  in  the  north  of  London  from  one  of  the 
cases  originating  in  the  Caledonia.  Thus,  while 
the  outbreak  was  stamped  out  in  the  north,  its 
focus  shifted  to  the  south-west  of  London.  Three 
persons  with  whom  the  valet's  wife  came  into 
contact  caught  smallpox  and  were  sent  here ; 
while  about  the  same  time,  a  woman  who  lived 
in  the  same  house  in  Victoria  Street,  and  had 
come  in  contact  with  her  or  her  husband,  was 
admitted  as  a  patient  to  a  general  hospital, 
and  died  there  of  a  severe  attack  of  confluent 
smallpox.  The  nature  of  this  patient's  illness 
was  unrecognised,  and  five  other  persons  who 
were  patients  or  employed  at  that  hospital, 
caught  smallpox  from  her,  and  were  sent  here. 
When  the  valet  died  in  Victoria  Street,  some 
linen  from  the  house  was  sent  to  a  laundry  at 
Chiswick,  and  another  centre  for  the  spread  of 
the  contagion  was  thus  furnished.  Again  the 
earlier  cases  were  unrecognised,  and  nine  patients 
were    admitted    in    consequence.      Nor   was   this 


ch.  i]  UNRECOGNISED  CASES  7 

quite  all,  for  when  the  valet  died,  his  brother  came 
to  London,  and  took  the  smallpox  back  with 
him  to  the  provincial  town  where  he  dwelt. 
Four  or  five  cases  of  smallpox  resulted. 

"So  far  as  is  known,  at  least  thirty  cases  in 
London  and  out  of  it  could  thus  be  traced  back 
to  the  Caledonia,  and  over  twenty  cases  to  the 
man  who  died  of  'measles'  in  Victoria  Street. 
This  is  a  somewhat  unusual  experience  nowadays, 
and  it  is  to  be  explained  by  the  repeated  mistakes 
in  diagnosis  which  were  made.  Thus  the  nature 
of  the  original  cases  from  the  Caledonia  was 
not  at  first  recognised.  The  man  in  Victoria 
Street  was  supposed  to  have  measles ;  the  patient 
taken  to  a  general  hospital  died  of  a  rare  skin 
disease,  the  name  of  which  has  escaped  me ; 
while  the  earlier  cases  in  Kensington  and  those 
in  the  provincial  town  were  classed  as  chickenpox. 

"  Early  in  April,  there  was  a  small  outbreak 
of  smallpox  in  St.  George's-in-the-East.  Five 
patients  were  sent  here  from  that  infirmary,  and 
two  more  from  the  same  part  of  London,  who  all 
appeared  to  owe  their  illness  to  a  common  source. 
The  first  to  fall  ill  was  a  boy,  who  was  treated  in 
the  infirmary  for  chickenpox,  the  true  nature  of 


8  HOW   TO   DIAGNOSE   SMALLPOX        [ch.  i 

whose     illness    was     not    perceived     until     other 
secondary  cases  had  occurred. 

"  The  cases  so  far  touched  on  form  the  bulk  of 
the  admissions  for  the  year,  but  it  may  be  worth 
while  to  allude  to  the  remaining  cases. 

"  In  February,  a  young  woman  was  admitted 
from  Greenwich.  She  was  shortly  to  have  been 
married,  but  she  died  here  of  hemorrhagic  small- 
pox. She  caught  smallpox  from  her  mother,  in 
whom  the  disease  was  of  a  similar  nature,  and  had 
a  similar  result.  How  the  mother  got  smallpox 
is  unknown,  nor  was  the  nature  of  her  illness 
recognised ;  she  was  stated  to  have  died  of  blood- 
poisoning. 

"  Three  persons,  members  of  the  same  family, 
were  admitted  from  Streatham,  in  August.  The 
father  of  two  of  the  patients  had  died  shortly 
before  their  admission.  His  illness  was  supposed 
to  have  been  due  to  measles.  He  seems  to  have 
caught  smallpox  from  a  son,  who  had  come  home 
on  leave  from  a  training  ship  at  Devonport.  The 
son  was  said  to  have  chickenpox. 

"  In  November,  two  fellow  servants  were 
admitted  from  a  house  in  Sloane  Gardens.  One 
of  them   has   barely   escaped   with    her   life.      It 


ch.  i]  UNRECOGNISED   CASES  9 

seems  probable  that  they  got  smallpox  from  their 
master.  They  told  me  he  had  been  suffering 
from  blood-poisoning  with  an  eruption  of  spots. 

"  It  has  been  mentioned  that  two  patients  were 
admitted  from  Orsett,  in  Essex  (in  July).  The 
first  patient  was  a  youth  in  the  Navy,  who  had 
returned  to  Orsett  on  leave  from  one  of  H.M. 
hospital  ships.  He  said  there  was  a  boy  there 
who  had  been  suffering  from  German  measles 
and  chickenpox,  a  double-barrelled  diagnosis,  very 
suggestive  of  smallpox.  The  second  patient 
admitted  caught  smallpox  from  the  first,  and 
died  here. 

"  I  think  it  may  be  said  justly  that  the  most 
part  of  the  cases  of  smallpox  which  occurred  in 
London  last  year,  might  have  been  prevented  very 
readily.  Had  the  mistakes  in  diagnosis  which  1 
have  recounted  not  been  made,  so  much  illness, 
much  suffering,  and  some  deaths  would  have  been 
avoided.  Smallpox  is  a  disease  which  in  practice 
seems  to  present  more  difficulties  in  its  detection 
than  do  most  others;  it  is  the  disease  in  which 
mistakes  are  of  most  moment;  and  yet  it  is, 
perhaps,  of  all  diseases,  that  in  which  a  certain 
diagnosis  can  be  arrived  at  in  almost  every  case." 


CHAPTER   II 

UNRECOGNISED   CASES   AND   THEIR   REMEDY 

In  the  next  year,  1901,  to  which  the  fol- 
lowing extract  relates,  though  mis-diagnoses 
do  not  stand  out  so  prominently,  the  results 
were  more  disastrous.  They  formed  the  begin- 
ning of  an  epidemic  comprising  nearly  10,000 
cases. 

Dr.  Ricketts  reported  : 

"  The  seeds  of  the  present  epidemic  were  sown 
in  June  (1901).  The  two  first  patients  admitted 
in  that  month  lived  in  Whitechapel  and  East 
Ham  respectively.  In  neither  case  could  the 
origin  of  the  disease  be  traced,  nor,  so  far  as  is 
known,  did  other  cases  develop  from  them.  Two 
more  important  foci  of  infection  appeared  at  the 
end  of  June:  (1)  A  man  who  had  visited  Paris 
returned  to  his  home  in  Streatham  and  developed 


ch.  n]  UNRECOGNISED  CASES  11 

smallpox  there;  he  died,  but  the  nature  of  his 
illness  was  not  appreciated.  A  relative  of  his  caught 
smallpox  from  him  and  was  admitted  here;  his 
linen  was  sent  to  a  laundry  to  be  washed,  and 
two  persons  working  in  that  laundry  also  got 
smallpox.  (2)  A  laundry  carman  working  in 
Hackney  caught  smallpox,  doubtless  from  the 
linen  of  one  of  the  customers  of  the  laundry ;  a 
laundrymaid  also  caught  the  disease  from  the 
same  source  ;  from  this  source  nine  others  con- 
tracted the  disease  in  July  and  August. 

"  Two  more  centres  were  noted  in  the  month 
of  July.  The  first  of  these  was  a  house  in 
Norfolk  Square,  Paddington,  the  housekeeper  and 
a  domestic  servant  employed  at  the  house  falling 
victims,  as  well  as  a  gentleman  who  was  in  the 
habit  of  visiting  there  ;  the  origin  of  the  disease 
in  this  case  could  not  be  ascertained.  The  second 
centre  was  in  Willesden,  and  the  disease  in  this 
case  appears  to  have  been  spread  by  means  of 
infected  bedding,  which  was  sent  to  Willesden 
to  be  disinfected  or  cleaned.  I  do  not  know 
whence  this  bedding  came,  but  three  persons 
caught  smallpox  directly  or  indirectly  from  this 
source. 


12  HOW  TO   DIAGNOSE   SMALLPOX       [ch.  ii 

'This  carries  us  up  to   the  end  of  July  and 
the    beginning    of    August,    when    a    few    cases 
occurred   in   the  west   of    London— cases    which 
were  apparently  unconnected,  but  which  probably 
came  from  a  common  source  and  were  the  fore- 
runners of  a  serious  outbreak.     The  first  of  these 
was   a  case  of  a   woman   of  French   nationality, 
who    lived    in    the    City    of    Westminster.      At 
the  same  time  occurred  the  cases  of  two  sisters 
who    lived    in    Marylebone;     a    sister    of    these 
patients  was  stated  to  have  had  chickenpox,  but, 
assuming   her  illness  to   have   been  smallpox,  its 
origin   was   unknown.      A   fourth   case   was  that 
of   a    German   waiter  at    the    Langham    Hotel. 
On   August    9th,   a   patient   was    admitted    who 
lived  in  Huntley  Street,  Tottenham  Court  Road  ; 
a  few  days  afterwards  two  patients  were  admitted 
from    Holborn,   another    from   St.    Pancras.      In 
none  of  these  cases  could  the  source  of  infection 
be    traced,    and,    generally    speaking,    the    cases 
seemed    to   be  unconnected.      But  the  common 
factor  was  that  their  places   of  residence,   their 
avocations  or  amusements,  took  them  into   that 
part    of   London    about    the    Tottenham    Court 
Road,    and    it    was    in    that    neighbourhood,   in 


ch.  n]  UNRECOGNISED   CASES  13 

some  crowded  streets  lying  on  the  west  side  of 
Tottenham  Court  Road,  that  smallpox  broke 
out  in  the  latter  half  of  August,  and  shortly 
assumed  an  epidemic  form.  Between  the  19th  and 
31st  August,  sixty-eight  patients  were  admitted, 
of  whom  all  but  eight  either  resided  in  the  district 
I  have  mentioned  or  appeared  to  have  caught 
the  disease  there.  In  September  the  disease 
continued  to  spread  to  all  parts  of  London.  Its 
prevalence  in  its  original  seat  continued  up  to 
the  end  of  the  year,  so  that  of  the  total  number 
of  cases  which  occurred  in  London  during  the 
year,  one-third  were  removed  from  St.  Pancras, 
Holborn  and  Bloomsbury.  But  there  was  not  a 
single  union  which  escaped  the  visitation. 

"From  what  has  been  said  it  will  be  seen 
that,  once  it  had  obtained  a  foothold,  the 
epidemic  developed  with  great  rapidity.  Thus 
on  August  19th,  there  were  only  fifteen  patients 
under  treatment  in  this  hospital.  In  eight  days 
this  number  increased  to  seventy-three.  In  a 
little  over  two  months  the  hospital  was  full  and 
patients  were  being  transferred  to  Gore  Farm, 
and  in  four  months  patients  were  being  admitted 
at  a  rate  of  upwards  of  thirty  a  day.     This  course 


14  HOW   TO   DIAGNOSE   SMALLPOX        [ch,  ti 

of  events  illustrated  once  more  the  fact  that 
outbreaks  of  smallpox  are  prone  to  occur  without 
warning,  and  to  reach  unpleasant  proportions 
with  great  rapidity ;  and  it  emphasises  the  need 
for  being  always  prepared  to  deal  with  an 
emergency." 

These  and  similar  reports  show  how  easy  it 
is  for  smallpox  to  creep  in,  establish  and  propa- 
gate itself,  undetected.  Prompt  recognition  of 
the  disease  is  seen  to  be  vital  to  effective 
control. 

That,  however,  is  by  no  means  a  simple 
matter.  Smallpox  diagnosis  is  a  subject  attended 
by  circumstances  which  are  altogether  excep- 
tional. Not  only  is  the  opportunity  of  studying 
smallpox  very  limited,  and  the  profession  much 
handicapped  thereby,  but  the  disease  itself 
presents  greater  difficulties  of  diagnosis  than  do 
most  diseases.  The  early  symptoms  are  common 
to  many  other  disorders ;  variations  from  type 
are  numerous  and  wide  ;  the  various  stages 
of  the  disease  present  remarkable  differences. 
The  consequence  is  that  smallpox  has  a  power 
of  deception  which  is  as  subtle  as  it  is 
formidable. 


ch.  ti]  UNRECOGNISED   CASES  15 

In  considering  what  can  be  done  to  meet  this, 
it  may  be  said  that  the  diagnosis  of  smallpox  is  in 
the  hands  of  a  few ;  that  they  cannot  impart  their 
knowledge,  and  that  missed  cases  cannot  be  helped. 
I  do  not  take  that  view.  On  p.  9,  Dr.  Ricketts 
has  been  quoted  as  writing  of  smallpox,  "  It  is, 
perhaps,  of  all  diseases,  that  in  which  a  certain 
diagnosis  can  be  arrived  at  in  almost  every  case." 
Considering  the  difficulties  which  cases  present, 
and  the  differences  of  opinion  which  they  are  apt 
to  occasion  among  us,  that  is  a  remarkable  state- 
ment and  might  well  be  challenged.  But  it  agrees 
with  my  own  experience,  and  I  believe  it  to  be 
true. 

I  take  the  explanation  to  be  this.  Accurate 
diagnosis  of  disease  results  from  the  correct 
reading  of  accessible  pathological  data.  In  some 
diseases,  as  for  instance  in  acute  lobar  pneumonia, 
these  data  are  easily  perceptible ;  in  others,  such 
as  in  meningitis,  they  exist  none  the  less,  but  are 
not  readily  accessible.  The  pathological  data  of 
smallpox,  however,  are  mainly  on  the  surface.  It 
may  be  said  of  smallpox  that,  with  very  few 
exceptions,  throughout  its  course  it  carries  with 
it    the    naked- eye    pathological    evidence.      The 


16  HOW  TO   DIAGNOSE   SMALLPOX       [ch.  n 

difficulty  is  to  read  this  evidence  aright.  Rashes 
resemble  hieroglyphics.  Though  the  writing  is  all 
there,  it  is  not  always  easy  to  read. 

Of  course  there  is  nothing  like  practical  work 
for  learning  the  subject ;  experience  shows,  never- 
theless, that  a  great  deal  of  useful  information  can 
be  imparted  in  the  study,  and  will  be  invaluable 
at  the  bedside,  as  opportunities  of  practice  occur. 
Sound  practical  knowledge  can  be  gathered 
from  the  written  page  even  when  actual 
smallpox  cannot  be  seen.  If  anyone,  who  is 
anxious  to  improve  his  knowledge  of  the  subject, 
studies  what  is  given  here,  he  can  learn  a 
great  deal  that  will  stand  him  in  good  stead  when 
he  meets  with  actual  cases  in  practice. 

To  illustrate  this,  reference  may  be  made  to 
the  reports  of  the  Metropolitan  Asylums  Board 
in  reference  to  smallpox  diagnosis.  Formerly, 
the  smallpox  hospitals  were  in  London  itself, 
and  patients  were  admitted  to  them  direct.  The 
hospitals  were  moved  out  of  London  on  account 
of  smallpox  occurring  in  their  neighbourhoods. 
Patients  then  were  sent  to  be  treated  in  hospital 
ships,  first  at  Greenwich,  and  then  near  Dart- 
ford  ;  now  the  ships  have  been  taken  away,  and 


ch.  n]  UNRECOGNISED   CASES  17 

the  hospitals  are  on  shore.  At  the  present  time 
patients  are  taken  by  a  land  ambulance  from  home 
to  a  riverside  wharf,  usually  South  Wharf  at 
Rotherhithe,  and  sheltered  there  till  the  ambulance 
steamer  takes  them  down  the  Thames  to  the 
shore  hospital  near  Dartford. 

Formerly  many  of  the  patients  directly  admitted 
were  found  not  to  have  smallpox,  and  some  method 
of  revising  the  original  diagnosis  was  necessary 
before  actual  admission  to  hospital.  In  the  year 
1892,  a  temporary  medical  officer  was  stationed  at 
South  Wharf,  Rotherhithe.  In  1893  a  medical 
officer  was  appointed  to  reside  there,  and,  in  the 
course  of  that  year,  shelters  were  erected  in  which, 
if  necessary,  patients  could  be  detained  and  kept 
under  observation.  It  was  the  duty  of  this  officer 
to  revise  the  original  diagnoses,  and  to  reduce  to 
a  minimum  the  admission  to  hospital  of  non- 
smallpox  cases.  In  1893,  of  2433  patients  sent 
on  to  hospital  for  admission,  73  turned  out  not  to 
have  smallpox,  that  is  about  3  per  cent,  passed  the 
diagnostic  screen  and  were  admitted.  The  next 
epidemic  year  was  1901.  Of  1603  patients  sent 
on  to  hospital  for  admission,  8  turned  out  not 
to  have  smallpox,  that  is  0*5  per  cent.      In  the 

c 


18  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  n 

following  year,  1902,  of  7208  patients  sent  on 
to  hospital  for  admission,  those  who  turned  out 
not  to  have  smallpox  were  3  in  number,  that  is 
0*025  per  cent. 

Various  factors  combined  to  produce  this 
improvement  in  results,  among  them  being  the 
provision  of  certain  administrative  facilities;  but 
the  main  factor  was  the  method  of  diagnosis  worked 
out  by  Dr.  Bicketts,  and  taught  by  him  to  his 
colleagues.  It  is  this  method  of  diagnosis  which 
I  desire  to  set  out. 


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Prevalence  of  smallpox  in  London  between  1885  and  1912.     The  curve  shows  the  cases  sent  for  admission  to  the  smallpox  hospitals. 


CHAPTER    III 

PRACTICAL   POINTS    IN   THE   METHOD    OF 
EXAMINATION 

In  this  chapter  I  propose  to  deal  with  some  of 
the  points  which,  apart  from  the  disease  itself, 
are  very  important  if  accuracy  in  diagnosis  is  to 
be  attained.  The  first  is  this.  The  commonest 
cause  of  smallpox  being  missed  is  that  its  possi- 
bility has  never  come  into  the  mind  of  the  medical 
attendant.  How  often  has  it  been  said,  "  Small- 
pox !  Why,  I  never  dreamt  of  smallpox  !  It  never 
came  into  my  head.  There  was  none  about,  and 
I  confess  it  never  occurred  to  me."  But  once 
the  possibility  of  the  disease  comes  to  mind,  once 
the  question  is  put  to  oneself,  the  whole  case  may 
be  cleared  up.  There  is  no  more  useful  habit  than 
that  of  reflecting,  when  confronted  by  a  case,  the 
diagnosis  of  which  is  not  perfectly  clear,  "  What 
else  can  this  be  ?  Can  it  be  this,  that,  or  so  on  ? " 
And   of  all  such   questions,  there   is   none   more 


20  HOW   TO   DIAGNOSE    SMALLPOX      [ch.  m 

important  than  this  one,  "  Can  it  be  smallpox  ? 
Would  smallpox  produce  this  ?  "  Such  a  question 
should  not  only  be  in  mind  when  smallpox  is 
prevalent,  but  also  when  it  is  not  epidemic ;  for 
it  is  precisely  at  such  a  time  that  cases  are 
most  easily  missed,  and  are  apt  to  do  the  worst 
mischief. 

Coming  now  to  the  examination  of  suspected 
cases,  we  find  that  there  are  three  details  of 
technique  which  especially  claim  attention.  They 
concern  the  manner  in  which  cases  are  examined. 
Their  neglect  has  led  to  many  wrong  diagnoses. 
The  first  detail  is  to  have  a  due  respect  for  the 
subtleties  of  smallpox.  The  want  of  this  is  a 
common  source  of  error.  It  is  apt  to  be  said,  "  I 
have  seen  plenty  of  smallpox,  and  have  studied 
cases  most  carefully.  I  know  it  well.  I  don't  think 
I  could  go  wrong."  That  is  a  fatal  attitude  of 
mind,  and  certain  to  lead  to  disaster.  Persons  of 
that  way  of  thinking  have  yet  to  buy  their  ex- 
perience, and  will  pay  for  it  very  dearly. 

To  diagnose  smallpox  successfully,  means  to 
approach  it  with  much  respect.  That  is  a  sine 
qua  lion.  The  more  of  it  one  sees,  the  more 
respectful  one  gets,  and  the  more  on  the  lookout 


ch.  in]         METHOD  OF  EXAMINATION  21 

for  the  extraordinary  cases  that  do  occur.  The 
closest  attention  must  be  given  to  every  individual 
case,  if  the  best  results  are  to  be  obtained. 

Our  next  point  is  a  commonplace  but  im- 
portant detail.  Before  giving  an  opinion,  it  is 
essential  to  see  the  whole  surface  of  the  body, 
and  as  much  as  possible  in  one  view.  The  full 
bearing  of  this  will  be  better  understood  when 
we  come  to  Chapters  IV  and  VI,  and  see  how 
frequently  a  correct  opinion  turns  on  a  com- 
parison of  one  area  of  the  skin  with  another. 
Bed  is  the  proper  place  in  which  to  examine 
a  patient ;  for  then  the  patient  and  his  coverings 
may  be  so  disposed  as  to  obtain  the  maximum 
results  with  the  minimum  of  time  and  incon- 
venience. 

A  bath  may  work  wonders  in  displaying  a  rash 
which  previously  was  invisible.  No  opinion  in 
the  negative  sense  should  ever  be  given  about 
a  patient  whose  skin  is  dirty,  till  he  has  had  a 
good  wash.  Late  cases  of  smallpox,  see  p.  99, 
may  have  no  other  reliable  evidence  about  them 
than  that  on  the  soles  of  the  feet.  A  girl,  whom 
I  saw  recently,  had  had  an  illness  some  three 
weeks   previously.      Her   skin   was    clear,   except 


22  HOW  TO   DIAGNOSE   SMALLPOX     [ch.  in 

for  some  slight  blemishes,  which  were  suspicious. 
A  glance  at  the  soles  of  the  feet,  which  had 
just  been  washed  and  were  clean,  clinched  the 
diagnosis  of  smallpox. 

The  last  point  is  the  necessity  for  a  good  light. 
The  absence  of  this  precaution  has  accounted  for 
many  missed  diagnoses.  Anyone  who  has  had  to 
see  a  succession  of  cases  first  by  very  dim  illumina- 
tion, and  later  by  an  adequate  light,  will  appreciate 
how  enormously  a  bad  light  adds  to  the  difficulties 
of  the  work.  It  is  one  of  the  special  difficulties  of 
seeing  cases  in  poor  homes,  and  may  make  an 
opinion  almost  impossible  to  give.  Such  a  case 
happened  to  me  recently.  I  went  into  a  little 
room,  a  cube  of  10  feet  with  a  big  double  bed  in 
it,  and  found  a  lad  and  a  girl  sitting  by  the  fire. 
It  was  still  daylight,  and  the  room  could  hardly 
be  called  dark,  but  it  was  badly  lit.  I  could  see 
the  girl  well  enough  to  recognise  her  easily,  if  I 
had  known  her  ;  she  did  not  seem  ill,  only  rather 
quiet  and  dull.  I  looked  at  her  hands  and  face, 
and  could  see  nothing  amiss.  Dissatisfied,  how- 
ever, I  took  her  into  the  backyard,  where 
the  light  was  fairly  good.  It  was  nearly  four 
o'clock  on  a  February  afternoon.     At  once  there 


ch.  in]  METHOD   OF  EXAMINATION  23 

was  visible  on  face,  hands  and  wrists  the  early 
papular  rash  of  smallpox,  many  of  the  spots 
being  no  more  conspicuous  than  the  rose  spots  of 
typhoid  fever. 

In  a  properly  equipped  receiving  room,  con- 
ditions exist  which  greatly  facilitate  diagnosis. 
The  patient  lies  at  full  length,  after  a  bath  if 
necessary,  in  a  blanket  gown,  at  a  convenient 
height,  and  under  an  ample  daylight  or  bright 
artificial  light.  Such  conditions  are  a  great  help. 
But  in  such  conditions  as  exist  in  many  poor 
homes,  when  you  are  asked  for  an  opinion  on 
a  patient  who  refuses  to  undress,  has  a  dirty 
skin,  or  is  placed  in  a  dim  or  flickering  light, 
you  should  withhold  your  opinion,  unless  the  case 
is  perfectly  clear. 

Such  details  of  examination,  as  I  have  men- 
tioned, may  be  of  direct  importance  to  the  physician 
as  well  as  to  the  patient.  An  error  of  diagnosis 
occasionally  brings  the  medical  attendant  into 
court  to  answer  charges  of  negligence  or  malpraxis, 
brought  by  an  aggrieved  patient  who  is  claiming 
compensation. 

I  have  heard  such  an  action  tried  in  the  High 
Court.     A   medical    practitioner    saw  a   child  in 


24  HOW  TO  DIAGNOSE   SMALLPOX     [ch.  id 

his  private  practice,  and  thought  she  had  small- 
pox;  so  also  did  the  Medical  Officer  of  Health 
who  saw  the  case  in  consultation  with  him.  They 
both  certified.  There  was  good  reason.  The 
rash  was  copious,  and  bore  a  close  resemblance 
to  that  of  smallpox.  In  the  sequel,  however,  the 
diagnosis  of  chickenpox  was  established  beyond 
all  doubt;  the  child's  mother  was  very  angry, 
and  brought  an  action  to  obtain  compensation  for 
the  damage  which  had  been  caused  to  her  busi- 
ness. Fortunately  counsel  for  the  defendant  was 
able  to  show  that  his  client's  opinion  was  arrived 
at  after  the  exercise  of  all  the  care  and  skill  which 
he  could  bring  to  bear.  He  had  seen  the  child  twice 
within  a  few  hours;  had  got  the  best  light  he 
possibly  could,  had  taken  all  the  clothes  off,  and 
examined  the  whole  surface  of  the  skin  thoroughly. 
Feeling  the  limitations  of  his  own  experience,  he 
had  called  in  another  opinion.  When  the  jury 
heard  all  this,  and  were  satisfied  that  the  de- 
fendant had  taken  every  possible  care  and  trouble, 
and  had  brought  all  his  ability  and  skill  to  bear 
on  the  case,  they  intimated  that  they  had  heard 
enough  and  gave  him  their  verdict.  But  had 
he  made  an   examination  of  the  patient,   which 


ch.  m]         METHOD   OF   EXAMINATION  25 

was  cursory  or  careless,  or  had  he  shown  a  lack 
of  due  and  reasonable  care,  then  the  issue  might 
have  been  very  different.  Certainly  both  judge 
and  jury  paid  particular  attention  to  the  degree 
of  detail  and  care  with  which  the  case  had  been 
examined.  That  seemed  to  weigh  with  them 
more  than  anything. 


CHAPTER   IV 

INDIVIDUAL  CASES  OF  SMALLPOX  CONSIDERED   WITH 
A   VIEW   TO   DIAGNOSIS 

In  considering  the  clinical  details  which  influence 
diagnosis,  it  is  advantageous  to  take  one  or  more 
individual  cases.  Once  the  points  are  clearly 
grasped,  it  is  not  difficult  to  apply  them  to 
other  patients  who  may  subsequently  be  seen. 

For  the  sake  of  clearness  the  various  points 
are  set  out  in  the  form  of  question  and  answer. 

"  Have  a  good  look  at  the  photos  of  these 
coloured  people;  see  plates  Nos.  1,  2,  3,  4;  a 
correct  diagnosis  can  readily  be  made  from  them. 
Disregard,  for  the  moment,  the  anatomical 
characters  of  the  individual  spots ;  regard  the 
rash  as  so  many  dots ;  and  examine  just  how 
they  are  arranged.  That  is  the  point  on  which 
we  have  now  to  concentrate  our  attention.  It 
is  a  useful  practice,  and  takes  only  a  few  minutes, 


ch.  iv]    INDIVIDUAL  CASES   OF  SMALLPOX        27 

to  dot  down  the  spots  of  an  actual  case  roughly 
on  a  diagram  and  see  how  they  lie.  First  of  all 
where  is  the  rash  scantiest  in  these  four  cases  ? 
Where  is  the  skin  most  clear  of  spots  ?  " 

"  On  the  front  of  the  child's  trunk,  on  the 
chest  and  belly." 

"  Yes.  The  spots  there  number  not  more 
than  ten  or  a  dozen,  and  the  area  of  skin  which 
they  occupy  is  large,  relatively  speaking.  Note 
this  then,  that  while  the  rest  of  the  skin  is 
materially  affected,  the  chest  is  lightly  covered, 
and  the  abdomen  shows  an  almost  clear  sheet 
of  unblemished  skin.  That  is  very  striking ;  and 
is  a  point  not  to  be  forgotten.  So  much  for 
where  the  rash  is  lightest.  Now,  where  is  it 
most  marked,  leaving,  for  the  moment,  the  legs 
out  of  account  ? " 

"  It  seems  thickest  on  the  face." 

"  That  is  so ;  it  is  noticeable  especially  on 
the  woman's  face." 

"  What  about  the  arms  ?  " 

"  The  rash  on  the  woman's  arms  is  not  so 
thick  as  that  on  the  face,  and  yet  thicker  than 
that  on  the  back." 

"  And  on  the  back  ?  " 


28  HOW   TO   DIAGNOSE   SMALLPOX      [ch.  iv 

"  There  it  is  thicker  than  on  the  chest.'1 

"  Quite  so.  We  have  now  got  some  of  the 
salient  features  of  the  distribution  of  the  rash, 
namely,  that  abdomen,  chest,  back,  arms,  face  are 
in  ascending  order  of  density." 

"  The  principle  underlying  this  simple  observa- 
tion is  one  of  much  importance,  and  very  valuable 
in  diagnosis ;  we  will  proceed  further  to  illustrate 
it.  As  you  look  at  the  rash,  which  you  see 
affects  every  part  of  the  surface,  and  you  know  is 
smallpox,  would  it  strike  you  as  odd  if  a  patient 
showed  exactly  such  a  rash,  with  this  exception,  that 
one  arm  from  the  shoulder  downwards  had  no  rash 
at  all,  and  was  perfectly  free  from  any  blemish  ? 
Would  that  seem  remarkable  ?  " 

"  I  think  it  would." 

"  Can  you  conceive  it  could  be  compatible 
with  smallpox  ? " 

"Hardly." 

"Quite  so.  It  is  not  compatible.  Neither 
is  it  possible  to  have  such  a  rash  with  both  arms 
or  with  the  back  clear,  or  to  have  such  a  rash 
on  the  face  and  the  rest  of  the  skin  clear,  or 
for  the  face  to  be  clear,  and  such  a  rash  to  be 
on  the  rest  of  the  body,  and  for   any  such  cases  to 


ch.  iv]    INDIVIDUAL  CASES  OF  SMALLPOX         29 

be  due  to  smallpox.  This  fact  has  an  important 
bearing  on  many  suspected  cases,  as  we  shall  see 
later.  It  is  especially  useful  to  get  a  clear  impres- 
sion of  the  various  areas  of  clear  skin,  and  of  pock- 
marked skin,  and  to  have  an  indelible  mental  picture 
of  them.     You  will  find  it  very  useful. 

"  Now  we  will  leave  the  lower  part  of  the  body 
and  the  minutiae  of  the  upper  part  for  later  con- 
sideration, and  go  to  some  other  matters. 

"  Supposing  this  man  walked  into  your 
surgery  in  his  ordinary  costume  and  you  suspected 
smallpox,  and  you  yourself  had  to  form  an 
opinion  about  him — an  opinion  which  you  had 
to  record  there  and  then  in  writing,  and  had 
to  act  upon  and  to  stand  by,  how  would  you 
go  to  work  ? " 

"  I  think  I  should  ask  him  when  he  fell  ill, 
and  if  he  had  had  any  vomiting,  6x  pain  in  the 
back." 

"Yes,  you  would  first  of  all  take  the  history. 
So  would  ninety-nine  people  out  of  a  hundred. 
It  is  the  way  we  are  all  taught ;  but  it  is  not  the 
plan  which  leads  to  the  best  results.  I  prefer  to 
follow  the  plan  of  leaving  the  history  to  the  last. 
It  seems  to   me  that,  if  the   man   is  accused   of 


30  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  iv 

smallpox,  so  to  speak,  and  you  are  to  judge  and 
sentence  him,  the  evidence  which  ought  to  weigh 
most  with  you  is  your  own  direct  observation,  and 
the  reading  of  what  is  before  you.  The  evidence 
which,  other  things  being  equal,  will  make  most 
impression  in  your  mind  is  that  which  gets  there 
first ;  and  if  the  evidence  which  you  first  take  into 
consideration  is  hearsay  evidence,  and  some  of  it 
mere  gossip,  you  have  to  bring  the  most  valuable 
evidence  of  all,  namely  that  proceeding  from  your 
own  observation,  to  a  mind  already  prejudiced ; 
and  it  will  not  weigh  as  fairly  with  you  as  if  it 
came  to  a  mind  absolutely  open.  What  is 
commonly  called  history,  when  taken  first,  must 
always  produce  a  bias,  consciously  or  unconsciously. 
I  would  rather  be  altogether  without  it,  till  all  the 
other  evidence  has  been  taken. 

"Moreover  the  history  often  is,  and  indeed  in 
the  nature  of  things  must  be,  unreliable ;  for  it  is 
often  but  hearsay  evidence  of  the  slightest  kind. 
It  is  easy  for  a  patient  to  misreport  it,  to  forget 
what  is  material,  and  exaggerate  or  underrate 
what  is  important.  There  may  be  every  tempta- 
tion to  minimise  his  illness  or  deny  it  altogether. 
There  may  be  the  strongest  inducement  to  conceal 


ch.  iv]     INDIVIDUAL  CASES   OF  SMALLPOX        31 

or  to  misrepresent  it.  In  the  case  of  a  foreigner, 
or  a  child,  or  some  one  very  ill  who  cannot  be 
cross-questioned  or  understood,  you  cannot  get  at 
the  facts  of  the  history  at  all,  try  as  you  may ; 
you  may  waste  much  time  and  in  the  end  have  to 
give  it  up. 

"  But,  apart  from  these  considerations,  let  us 
suppose  that  the  history  which  you  have  got  is 
a  correct  statement  of  what  has  happened.  What 
is  it  likely  to  be  ? " 

"The  patient  might  say  that  he  felt  queer 
and  sick  on,  say,  a  Sunday  morning;  his  head 
was  bad,  his  back  and  limbs  ached  and  he  was 
weak  in  the  knees ;  he  was  miserable  and  good 
for  nothing;  he  got  no  better  as  the  day  went 
on ;  he  tried  to  take  his  tea  but  was  sick  after 
it ;  he  shivered,  went  to  bed  early  with  headache ; 
felt  very  hot,  slept  badly  and  dreamt  much.  On 
Monday  was  sick  again ;  couldn't  eat  anything, 
had  aches  and  pains  all  over,  especially  in  the 
back ;  and  felt  very  miserable.  Got  up  and  sat 
over  the  fire  shivering,  and  had  soon  to  go  to  bed 
again.  On  Tuesday  felt  a  shade  better.  That 
day  he  noticed  some  red  spots  on  his  forehead  and 
wrists.     The  next  day,  Wednesday,  they  were  all 


S2  HOW  TO   DIAGNOSE   SMALLPOX       [oh.  rv 

over   his   face,  and   on   his   arms   and  hands   and 
elsewhere  ;  and  he  felt  decidedly  better." 

"  That  sounds  a  useful  history,  and  one  which 
throws  considerable  light  on  the  diagnosis.  But 
might  it  not  be  the  history  of  a  case  of  chicken- 
pox  ?  What  do  you  say,  for  instance,  to  these 
notes  of  a  case  which  came  under  my  observation 
on  the  4th  day  ? 

"  '  A.B.,  male,  aged  20  ;  medical  student. 
"  e  Bay  1.    Taken  ill  acutely  with  fever.     Temperature  102°  ;  malaise  ; 

shivering  and  general  aching. 
"  '  Bay  2.     Pyrexia  continued  ;  malaise  ;  patient  unfit  for  any  work. 
f ' e  Bay  3.    General    improvement ;     papules    noticed     on    chin    in 
evening.' 

"  Would  not  this  history  strongly  incline  you 
to  smallpox  ? " 

"  I  think  it  would." 

"  Well,  if  you  rely  much  upon  histories,  you 
would  have  good  reason.  Chicken  pox  in  adults 
often  takes  a  severe  form  ;  the  initial  illness  may 
be  alarming,  and  differ  but  little  from  that  of 
smallpox.  There  is  no  definite  mention  of  prostra- 
tion in  this  latter  history,  though  my  recollection 
is  that  it  had  been  present.  One  difference  between 
it  and  yours  is  that  this  contains  no  note  of 
vomiting.  The  occurrence  of  vomiting  in  a  history 
of  that  kind  is   in   favour  of  smallpox ;    but  the 


ch.  iv]    INDIVIDUAL  CASES  OF  SMALLPOX  33 

absence  of  vomiting  from  the  history  does  not 
negative  that  disease.  In  point  of  fact,  my  note  on 
A.  B.  goes  on  thus  : — 

(i  e  Day  4.  Patient  had  been  certified  to  have  smallpox  ;  upon  which 
certificate  he  is  sent  to-day  to  the  Receiving  Station 
for  admission  ;  an  abundant  eruption  is  present.  The 
diagnosis  is  not  confirmed,  and  the  patient  is  found  to 
have  chickenpox.' 

"  So  that  even  in  this  case,  where  your  history 
is  an  accurate  account  of  what  has  passed,  it  is 
apt  to  lead  you  astray.  That  is  what  experience 
shows  again  and  again.  And  commonly  histories 
are  not  correct;  they  have  to  be  treated  with 
great  discrimination.  Reliance  on  them  is  one 
of  the  commonest  sources  of  error.  At  the  Re- 
ceiving Station  it  became  a  matter  of  routine  to 
take  the  histories  last  in  the  examination.  Often 
we  had  to  do  without  them,  because  patients  were 
too  confused  or  ill  to  make  any  statement." 

It  is  necessary  here  to  add  one  or  two  provisos. 
I  do  not  wish  to  underrate  the  value  of  a  story 
that  may  have  come  to  your  knowledge  indicating 
a  suspicion  of  smallpox  in  some  one  whom  you 
have  not  seen.  You  may  hear  that  so-and-so 
has  "the  influenza  with  spots,"  or  "chickenpox 
and   German   measles,"   or   "blood-poisoning  and 


34  HOW  TO   DIAGNOSE   SMALLPOX       [ch.  iv 

spots."  Such  a  story  should  be  promptly  followed 
up.  It  raises  a  strong  suspicion.  It  makes  a 
prima  facie  case,  and  requires  further  investi- 
gation. But  once  an  individual  patient  comes 
under  examination,  avoid  letting  him  or  anyone 
speak  to  you  about  the  history  of  the  case,  until 
you  have  completed  your  own  examination. 

My  advice  is  to  try  first  to  read  the  open 
book  before  you;  the  writing  is  all  there.  I 
mean,  of  course,  the  rash  as  displayed  on  the  skin. 
To  be  groping  about  for  a  history  is  to  lean  upon 
rotten  supports  which  you  are  better  without.  Sir 
George  Murray  Humphry  used  to  say,  of 
examining  cases  in  general,  "  Eyes  first.  Hands 
next.     Tongue  last  and  least." 

If  such  a  patient  as  we  have  supposed  should 
walk  into  your  surgery  and  you  should  suspect 
smallpox,  and  you  want  to  form  a  correct  opinion 
in  the  minimum  of  time,  the  best  way  is  to  cut 
conversation  short,  have  the  skin  as  far  as  the  waist 
uncovered,  with  a  suitable  loose  wrap  if  necessary, 
and  to  place  the  patient  in  the  best  possible  light, 
the  forearms  being  crossed  in  front  of  the  chest. 
Let  the  eruption  then  speak  for  itself. 

I  should  like  here  to  mention  a  useful  practical 


ch.iv]    INDIVIDUAL   CASES   OF  SMALLPOX        35 

method  in  examination  which  has  already  been 
alluded  to  on  p.  27.  It  is  always  helpful,  and 
especially  so  when  a  case  is  not  clear.  At  the 
Receiving  Station  I  endeavoured  to  make  a 
practice  of  plotting  out  the  rash  of  every  non- 
smallpox  case,  on  one  of  those  red  diagrams  of  the 
figure  which  are  sold  by  the  medical  booksellers. 
I  also  made  a  written  note  of  the  case,  according 
to  a  short  series  of  case  headings.  It  was  a  most 
useful  practice,  which  I  recommend  strongly  to 
anyone  similarly  placed.  Incidentally,  it  was 
evidence  of  care  having  been  exercised,  and  was 
useful  subsequently,  if  a  question  was  raised  about 
the  correctness  of  the  diagnosis. 

The  act  of  dotting  in  the  rash  compels  close 
observation  of  its  distribution,  and  often  of  itself 
leads  to  a  correct  solution.  We  shall  see  presently 
that  a  diagnosis  of  smallpox  can  sometimes  be 
made,  after  all  the  scabs  have  gone,  by  noting  the 
situations  of  the  scars  or  stains  which  have  been 
left  on  the  skin  by  the  rash.  Make  a  diagram 
therefore,  no  matter  how  rough,  of  any  case  that  is 
not  perfectly  straightforward.  You  will  be  surprised 
how  much  it  may  help  you.  It  may  by  itself  clear 
up  a  case  that  has  puzzled  you  very  much. 


CHAPTER   V 

INDIVIDUAL  CASES.      OTHER  FEATURES  OF  THE  RASH 

"  Let  us  now  resume  our  consideration  of  details 
of  the  rash.  Having  decided  to  postpone  taking 
the  history,  what  point  about  the  case  would 
you  care  to  take  next  ? " 

"  I  should  examine  the  spots  closely,  and  see 
if  they  had  the  characteristic  appearances  of  the 
rash  of  smallpox." 

"  Such  as  what  ?  " 

"  Well,  to  see  if  the  spots  were  umbilicated  or 
shotty." 

"  Yes,  of  course ;  that  is  what  we  have  all 
been  taught,  that  the  hall  marks  of  smallpox  are 
umbilication  and  shottiness.  It  is  a  characterisa- 
tion absolutely  wide  of  the  mark  for  purposes 
of  diagnosis.  The  words  are  uncommon,  and 
easy  to  remember  ;  they  are  a  pair  of  favourite 
old  friends  which    impressed  us  as  students,  and 


ch.  v]      OTHER  FEATURES   OF  THE   RASH  37 

have  stuck  by  us  from  our  medical  youth 
upwards.  It  is  only  when  we  come  to  test  them 
in  the  diagnosis  of  smallpox  that  we  see  what  an 
unreliable  pair  they  are ;  they  are  hardly  of  any 
use  at  all.  Are  you  going  to  say  that  the  absence 
of  umbilication  excludes  smallpox  ?  " 

"  I  should  hardly  say  that." 

"  No  ;  the  absence  of  umbilication  is  a  point  of 
almost  no  importance  as  against  smallpox.  Let  us 
consider  for  a  moment  what  umbilication  means. 
As  the  pock  passes  from  papule  to  vesicle,  there 
is  a  flattening  or  positive  dimpling  of  its  top.  It 
depends  on  this.  Inflammatory  serum  is  exuded 
between  the  epithelial  cells  and  collects  among  them, 
the  tension  thus  exerted  being  what  gives  firm- 
ness to  the  papule  ;  soon  the  tissues  yield  to  the 
fluid  pressure,  the  epithelial  strands  give  way, 
the  fluid  collects  into  a  bead,  and  a  vesicle  is 
formed ;  the  unsupported  part  of  its  envelope, 
namely,  that  towards  the  surface  of  the  skin,  yields 
and  thins ;  but  complete  and  regular  spherical 
expansion  is  retarded  by  the  strands  of  epithelial 
cells  among  which  the  fluid  has  collected,  and  they 
tie  together  the  roof  and  floor  of  the  vesicle. 
Thus  the  roof  may  be  flattened  or  dimpled.    That 


38  HOW  TO   DIAGNOSE  SMALLPOX        [ch.  v 

is  your  umbilication.  Soon  these  internal  ties 
soften,  as  pustulation  advances ;  they  disappear 
altogether,  and  then  the  pock  assumes  the  familiar 
dome-topped  form.  Hence,  at  best,  umbilication 
can  only  be  a  transitory  phenomenon  lasting  for 
a  day  or  two  ;  for  the  rest  of  the  time  umbilication 
must  be  absent. 

"  Moreover,  in  some  cases,  and  those  among  the 
most  severe  and  infectious,  umbilication  may  never 
be  present  from  beginning  to  end.  In  some  of 
the  worst  cases  the  invading  poison  seems  over- 
whelming ;  no  vigorous  reaction  of  the  tissues 
takes  place  ;  the  vesicles  are  but  feebly  expanded, 
and  little  or  no  umbilication  is  possible.  On  the 
other  hand,  a  chickenpox  rash  is  not  infrequently 
marked  by  umbilication.  A  spurious  kind  of 
dimpling  is  not  at  all  uncommon,  from  the 
vesicles  becoming  broken  and  their  walls  falling 
in ;  and  occasionally  a  true  umbilication  is  seen 
even  in  chickenpox.  In  a  word  umbilication  is 
a  weak  reed  to  lean  on  ;  the  sign  is  very  incon- 
stant ;  it  is  often  absent  from  well-marked  small- 
pox ;  when  it  is  present,  the  diagnosis  is  usually 
clear  without  it ;  as  a  diagnositic  criterion  it  is 
almost  without  value. 


ch.  v]      OTHER   FEATURES   OF  THE   RASH  39 

"  Then  you  have  spoken  of  shottiness.  How 
often  that  sign  has  led  to  cases  being  sent  as 
smallpox  that  really  were  not !  Repeatedly  I 
have  heard  it  said,  '  Well,  I  found  the  rash  was 
shotty  and  I  didn't  care  to  hesitate  any  longer.' 
It  is  certainly  wise  to  err  on  the  right  side ;  but 
what  we  are  here  considering  is  how  to  get 
accurate  results  both  ways. 

"  By  shottiness  is  usually  meant  that  a  papule 
feels  firm  and  hard  in  the  skin,  when  it  is  felt 
against  a  bone,  as  for  example  the  frontal  bone. 
At  that  rate  acne  is  shotty,  chickenpox  in  the 
adult  is  almost  always  shotty ;  so  are  many 
other  skin  eruptions.  I  recall  several  cases  of 
mosquito  bites,  for  instance,  in  which  the  spots 
were  as  hard  and  •  shotty '  as  anything  could  be. 
How  is  this  sign  going  to  help  you  in  the 
differential  diagnosis?  Moreover,  shottiness,  even 
if  it  were  of  any  help,  is  only  available  during 
the  papular  stage,  and  during  no  other  stage  of 
the  rash. 

H  It  is  perfectly  true  that  at  that  stage  the 
pock  is  usually  a  tense  sphere  lying  deep  in  the 
skin.  Dr.  Ricketts  advises  that  the  right  way 
to  estimate  the   depth  of  a  lesion  is  to  pick  up 


40  HOW   TO   DIAGNOSE   SMALLPOX       [ch.  v 

a  loose  fold  of  the  skin  and  roll  it  backwards 
and  forwards  between  the  finger  and  thumb.  A 
good  idea  of  the  depth  of  the  pock  can  thus  be 
formed.  But  that  is  not  what  is  meant  by  shotti- 
ness  as  the  term  is  commonly  used ;  what  is 
usually  meant  is  the  hard  feeling  of  a  spot  when 
pressed  by  the  finger  against  a  bone.  It  is 
said  that  when  this  sign  is  found,  smallpox  may 
be  strongly  suspected,  or  definitely  diagnosed. 
When  the  sign  is  not  found,  it  is  said  smallpox 
can  be  excluded.  As  a  matter  of  fact,  there 
could  not  be  a  greater  mistake  than  this  last 
observation.  What  would  you  say  to  this 
question  ?  Is  it  possible  for  a  severe  attack  of 
smallpox  to  occur  in  which  throughout  the 
papular  and  vesicular  stage  the  rash  is  not 
firm  or  hard  at  all  ?  " 

" 1  don't  see  how  it  could  fail  to  be  firm  and 
hard  at  some  time  during  the  papular  or  vesicular 
stage." 

"That  idea  is  incorrect;  and  it  is  material  to 
emphasize  the  point  because  it  may  easily  lead  to 
a  severe  case  of  smallpox  being  missed.  It  is 
precisely  the  worst  class  of  smallpox,  of  the  most 
infectious  type,  that  is  apt  to  have  a  soft,  almost 


ch.  ▼]      OTHER   FEATURES   OF  THE   RASH  41 

velvety  papular  rash.  Let  me  give  you  a  case 
in  point.  D.  L.  was  a  little  boy  certified  to  have 
smallpox.  On  his  forehead  and  face  he  had  a 
well-marked  papular  rash  which  was  as  soft  and 
velvety  as  any  rash  could  be.  It  resembled 
closely  the  rash  of  morbilli,  but  was  complicated 
by  a  pre-existing  scaly  condition  of  the  skin,  of 
some  standing.  There  was  no  shottiness  at  all 
about  the  papular  rash.  The  patient  was  bright 
and  talkative,  and  played  with  his  toys.  On  the 
day  following,  the  general  condition  and  the 
appearance  of  the  rash  was  much  the  same.  The 
next  day  saw  a  great  change.  The  child  was 
obviously  ill,  and  much  of  the  rash  was  marked 
by  low  flat  vesicles.  He  had,  in  point  of  fact,  an 
attack  of  smallpox  of  almost  the  worst  type." 

It  is  especially  in  the  worst  type  of  case  that 
you  expect  to  find  a  low,  soft  rash,  in  cases  in 
which  the  potency  of  the  poison  appears  com- 
pletely to  overpower  the  healthy  working  of 
the  tissues,  and  but  a  feeble  reaction  takes 
place.  The  spots,  instead  of  being  centres  of 
strong  reaction  and  inflammation,  are  dull,  flat, 
soft  and  delayed  in  maturation.  Such  a  rash  is 
especially  apt  to  be  associated  with  a  severe  and 


42  HOW  TO  DIAGNOSE   SMALLPOX        [ch.  v 

confluent,  or  with  a  haemorrhagic  attack,  and  with 
a  low  range  of  fever.  In  this  connection,  1 
would  give  a  word  of  warning  about  the  class  of 
case,  very  severe  confluent,  in  which  the  face  is, 
as  it  were,  covered  by  one  huge  papule,  which 
slowly  raises  the  skin  in  one  sheet.  The  lesion 
in  such  cases  is  apt  to  be  completely  overlooked 
by  the  untrained  eye ;  and  that  is  not  surprising ; 
for  the  face  may  appear  to  have  nothing  the 
matter  with  it,  till  it  is  closely  inspected;  then 
the  features  may  be  noticed  to  be  only  a  trifle 
full,  or  a  little  bloated ;  and  the  discovery  is 
made  that  the  patient  is  suffering  from  a  type  of 
the  disease  which  is  absolutely  fatal. 

While  we  are  on  this  part  of  our  subject,  there 
is  one  more  sign  that  may  be  mentioned  and 
dismissed,  and  that  is,  loculation.  The  smallpox 
vesicle  is  said  to  be  multilocular,  and  the  chicken- 
pox  vesicle  to  be  unilocular.  That  is  often  the 
case  ;  but  I  have  found  the  point  to  be  of  little 
assistance  in  practice.  And  it  is  not  always  the 
case.  I  recall  three  young  children,  members  of 
the  same  family,  unvaccinated,  in  whom  the  rash 
on  the  first  and  second  day  looked  as  though  the 
skin  had  been  touched  in  a  number  of  places  by 


ch.  v]     OTHER   FEATURES   OF  THE   RASH         43 

a  hot  substance  of  the  thickness  of  the  top  of  an 
ordinary  cedarwood  penholder.  The  skin  was 
marked  by  what  looked  like  a  number  of  super- 
ficial burns.  The  rash,  especially  in  one  of  the 
children,  had  just  the  appearance  of  chickenpox. 
The  pocks  themselves  were  strictly  unilocular; 
if  one  was  pinched,  it  collapsed  on  slight  pressure, 
without  any  pain  to  the  patient,  and  left  an 
irregular  pellicle,  lying  flat  and  collapsed.  But 
the  rash  of  all  these  patients  developed  in  un- 
mistakable fashion,  and  they  went  through  mild 
but  definite  attacks  of  smallpox. 

You  may  say,  perhaps,  after  reading  this, 
that  it  seems  as  if  all  the  old  ground  was  being 
taken  from  under  your  feet ;  that  these  are  the 
very  clinical  characteristics  on  which  you  have 
learnt  to  rely.  That  may  be  so.  I  have  no 
brief  against  the  traditional  criteria.  I  do  not 
deny  that  they  are  often  present.  But  if  you 
ask  me  of  what  value  they  have  been  to  me  in 
the  diagnosis  of  the  cases  which  I  have  seen,  I 
can  only  say,  very  little,  if  any. 


CHAPTER   VI 

THE   EXPLANATION   OF   THE    DISTRIBUTION 
OF   THE    RASH 

The  last  chapter  contained  a  criticism  of  some  of 
the  traditional  features  of  the  rash  of  smallpox ; 
not  because  they  did  not  exist,  but  because  they 
were  exaggerated  in  importance ;  and  especially 
because,  when  it  came  to  diagnosis,  they  were  apt 
to  be  misleading  as  well  as  useless.  These  features 
often  figure  in  descriptions  of  the  disease.  It 
would  be  more  useful  to  describe  it  in  some 
such  words  as  the  following  : — 

Smallpox  is  an  acute  fever  characterised  by 
an  eruption  the  foci  of  which  are  situated  deeply 
in  the  skin,  and  run  an  inflammatory  course  from 
papule  to  scab  ;  the  eruption  having,  in  general, 
a  symmetrical  distribution,  and  especially  favouring 
sites  of  irritation. 


ch.vi]    THE   DISTRIBUTION   OF  THE   RASH        45 

"  To  this  last-mentioned  feature  of  smallpox, 
in  particular,  let  us  now  turn.  It  is  the  irritated 
surfaces  which  I  would  especially  impress  on 
your  attention. 

"Referring  to  the  photographs  again,  do  you 
notice  anything  peculiar  about  the  rash  on  the 
woman's  right  hand  ?  " 

"There  is  a  little  patch  of  eruption  there 
which  looks  thicker  than  the  rest." 

"Yes,  that  is  so;  it  is  important;  it  is  a 
little  confluent  cluster  of  pocks ;  and  if  you  look 
again,  you  will  see  that  there  is  another  similar 
patch,  only  smaller,  at  the  root  of  the  little  finger. 
On  the  left  wrist  also  there  is  a  conspicuous  patch 
of  eruption.  They  are  no  chance  happenings, 
but  are  of  real  significance ;  could  we  have  ques- 
tioned the  woman,  she  would  probably  have  told 
us  that  it  was  just  at  those  places  that  she  had 
cut  or  scratched  or  burnt  herself,  or  had  had  some 
kind  of  sore  or  irritated  place  before  the  rash 
came  out.  Next  note  particularly  the  rash  on 
the  front  of  the  thighs  and  legs  of  the  child  who 
is  standing  up.  Can  you  form  any  idea  why  the 
rash  should  be  so  thick  there  ?  " 

"  It  does  not  seem  obvious." 


46  HOW  TO   DIAGNOSE   SMALLPOX       [oh.  vi 

"  The  explanation  is  found  in  the  position  of 
the  other  child.  You  will  notice  that  as  the 
child  is  held  and  carried,  the  front  of  the  thighs 
and  legs  are  rubbed  against  the  woman's  dress  ;  and 
it  is  just  those  parts  that  are  rubbed  that  form  the 
situation  most  affected  by  the  rash  as  seen  in 
the  child  standing  up.  That  is  the  kind  of 
phenomenon  you  will  often  see  in  smallpox  rashes. 
It  is  always  important  to  look  over  the  details 
of  a  rash  and  see,  for  instance,  how  it  is  arranged 
on  the  face  and  on  the  feet,  and  if  there  is  any 
other  irritated  surface  especially  marked  by  the 
rash;  conversely,  if  any  protected  surface  is 
especially  shunned  by  it. 

"  It  is  in  these  considerations  that  the  key  lies 
to  the  understanding  of  how  to  diagnose  smallpox  ; 
I  will  now  endeavour  to  explain  fully  the  under- 
lying principle." 

Curschmann  wrote  on  smallpox  in  Von 
Ziemssen's  "Cyclopaedia  of  Medicine,"  p.  359, 
edn.  1875,  as  follows  : — 

"  Portions  of  the  skin,  upon  which  mechanical 
or  chemical  irritation  has  acted,  either  before 
infection  or  during  the  stage  of  incubation,  are 
usually  affected    in   a   very  characteristic  manner. 


ch.  vi]    THE   DISTRIBUTION   OF  THE    RASH      47 

Even  when  the  eruption  is  extremely  scanty 
upon  the  remainder  of  the  body,  the  pustules 
here  are  usually  very  abundant,  and  frequently 
even  confluent. 

"  This  behaviour  of  the  exanthem  comes  most 
frequently  under  observation  where,  shortly  before, 
irritating  inunctions  or  pencillings  with  iodine 
have  been  made,  sinapisms  or  drawing  plasters 
applied,  or  contusions  or  superficial  erosions  have 
taken  place.  A  case  especially  striking  in  this 
regard  presented  itself  to  me  in  a  man  who  had 
been  seriously  infested  with  body  lice  before  his 
infection.  He  came  in  with  varioloid  of  moderate 
severity,  and  exhibited  numerous  scratches  ex- 
tending over  the  whole  body  studded  with 
pustules,  crowded  thickly  one  upon  another  like 
pearls  on  a  string,  and  partly  confluent.  Many 
of  these  scratches  were  three  or  four  inches  in 
length,  and,  at  a  distance,  gave  the  patient  the 
appearance  of  having  been  tattooed. 

"  It  would  seem  easy  upon  these  interesting 
facts  to  construct  theoretical  conclusions  respecting 
the  causes  of  the  density  and  distribution  of  the 
variole  eruption  in  ordinary  cases,  but  we  do 
not     get    beyond    the    preliminary    speculation. 


48  HOW   TO   DIAGNOSE   SMALLPOX       [ch.  vi 

Further  observations,  however,  and  especially 
experimental  research,  may  prove  of  great  value 
in  this  inquiry,  and  perhaps  clear  up  the  principal 
points.  I  will  not  omit  to  mention  that,  according 
to  my  experience,  the  conditions  of  the  skin  in 
question  give  occasion  to  this  peculiarity  of  the 
localisation  of  the  pocks  only  when  existing 
before  infection  or  in  the  stage  of  incubation. 
On  the  contrary,  when  I  produced  such  conditions 
of  the  skin  experimentally,  in  the  initial  stage 
(by  sinapisms,  painting  with  iodine,  etc.),  the 
eruption  was  never  thicker  here  than  in  other 
localities." 

This  uncommon  density  of  the  eruption, 
mentioned  by  Curschmann,  has  been  noticed  by 
many  observers,  and  instances  may  be  noted  in 
almost  any  collection  of  smallpox  photographs. 
Among  many  cases  that  I  recall — the  phe- 
nomenon is  one  of  frequent,  even  common, 
occurrence — was  a  rash  of  excessive  density  on 
the  feet  of  a  certain  male  patient  admitted  with 
smallpox.  He  had  a  severe  attack,  with  a  copious 
eruption  ;  and  the  rash,  I  recollect,  was  well  marked 
on  his  face ;  on  his  forearms  and  hands  it  was  later, 
and   less  marked  ;   the  rest   of  the   skin  at   that 


ch.vi]    THE   DISTRIBUTION   OF  THE   RASH        49 

stage  was  almost  free  from  blemish  ;  but  his  feet 
showed  a  dense  rash,  particularly  on  the  under 
and  inner  sides,  and  on  the  soles,  and  there  it 
was  fully  vesicular.  The  appearance  of  the  front 
of  the  body  as  a  whole  was  very  striking.  The 
red  face  and  hands,  the  pale,  unblemished  skin  of 
the  trunk  and  limbs,  and  then  the  red,  inflamed 
feet  below,  marked  with  clear  vesicles  as  closely 
set  as  the  cells  of  a  honeycomb.  This  man  hap- 
pened to  be  a  War  Office  messenger,  and  was  new 
to  his  work ;  the  feet  had  been  chafed  by  his 
unusual  exercise. 

Another  striking  case  occurred  in  a  man  who 
was  tramping  the  country  in  hot  summer  weather. 
I  think  he  had  been  haymaking.  At  any  rate, 
he  had  been  wearing  his  shirt  open  over  his 
chest,  and  that  part  of  his  skin  was  sunburnt, 
dirty,  sweaty  and  chafed.  He  had  a  mild  attack 
of  smallpox  and  a  slight  rash.  But  much  the 
thickest  portion  of  the  rash  was  on  the  front  of  the 
chest,  over  this  sunburnt  surface ;  the  rash  was 
thicker  there  than  on  his  hands  or  any  other  part. 
I  may  say  in  passing,  that  it  is  in  hot  weather 
that  I  have  found  the  most  anomalous  rashes 
to  occur,  both  of  smallpox  and  chickenpox.     That 

E 


50  HOW  TO   DIAGNOSE   SMALLPOX      [ch.  vi 

is  probably  due  to  the  skin  being  then  subjected 
to  the  combined  influence  of  heat,  perspiration, 
dirt,  and  friction. 

Another  remarkable  case  occurred  during  the 
inspection  of  a  common  lodging-house.  In  order 
to  pick  out  any  cases  of  smallpox  that  might 
be  occurring,  daily  inspection  of  the  inmates  was 
necessary.  This  was  done  while  the  men  were 
in  bed.  One  of  the  inspectors  was  acute  enough  to 
observe  that  a  pair  of  feet  sticking  out  of  the 
end  of  a  bed  had  some  spots  on  them.  At  first 
sight  the  spots  were  not  very  remarkable.  On 
closer  examination  they  were  seen  to  be  vesicular 
with  slight  reddish  areolae.  There  were  about  a 
dozen  or  twenty  spots  on  the  two  feet  together. 
They  were  the  only  spots  the  patient  had  about  him, 
except  for  one  or  two  inconspicuous  and  appar- 
ently trifling  papules  which  he  had  upon  his  face. 
I  had  no  hesitation  in  pronouncing  the  man  to 
have  smallpox.  He  was  a  hawker  and  constantly 
standing  and  walking  about ;  he  was  footsore  and 
the  rash  appeared  first  on  his  feet.  Other  spots 
came  out  later,  on  his  feet,  on  his  hands,  and 
face,  and  elsewhere ;  he  passed  through  a  mild 
attack. 


ch.vi]    THE   DISTRIBUTION   OF  THE   RASH        51 

Curschmann  did  not  get  beyond  preliminary 
speculation,  but  pointed  out  that  further  obser- 
vation might  clear  up  the  principal  points.  This 
was  done  by  Dr.  Ricketts. 

He  considered  exceptional  instances  like  those 
quoted ;  such  as  were  marked  by  a  clustering 
of  the  rash  at  the  site  of  vaccination,  or  around 
a  mustard  plaster  put  on  for  the  pain  in  the 
back.  He  passed  to  consider  other  not  uncommon 
sites  of  irritation,  such,  for  instance,  as  the 
knee,  where  a  ring  of  pocks  has  marked  the 
places  where  the  garters  have  chafed ;  or  the 
shoulders,  which  may  show  similar  but  less  well 
marked  signs  of  the  friction  of  braces.  He 
came  to  see  that  the  only  factor  common  to 
these  various  sites  was  the  disturbance  of  the 
cutaneous  circulation  due  to  an  irritation  which 
preceded  the  appearance  of  the  rash.  He  formed 
the  hypothesis  that  such  circulatory  disturbance 
was  the  factor  determining  the  incidence  of  the 
rash.  This  was  confirmed  by  the  converse  hold- 
ing good,  to  some  extent  at  least,  namely,  that  a 
limb  well  splinted,  for  instance,  showed  less  rash 
than  a  limb  in  ordinary  use. 

He  argued  that,  if  this  hypothesis  were  correct, 


52  HOW   TO   DIAGNOSE   SMALLPOX      [ch.  vi 

it  should  hold  good  when  applied  to  other  phe- 
nomena of  the  rash.  He  found  it  did  hold  good, 
and  that  it  applied  to  the  trivial  irritation  of  the 
skin  in  every-day  life ;  and  also  to  the  protection 
which  parts  of  it  receive. 

In  order  to  understand  this  thesis  fully, 
some  actual  cases  should  be  examined  in  detail. 
Look  at  the  foot.  Look  at  the  dorsum,  and  see  how 
the  prominent  tendon  is  picked  out  by  the  rash,  and 
how  free  from  rash  are  the  soft  parts  beneath  the 
toes ;  notice  the  signs  of  chafing  round  the  ankle ; 
in  some  patients  you  may  correctly  infer  that  they 
wore  shoes,  the  upper  edges  of  which  irritated  the 
skin,  and  provided  a  favourable  site  for  the  rash. 

Look  at  the  knee  joints  and  see  which  aspect 
is  most  marked  with  rash,  the  knees  or  the  popliteal 
spaces ;  see  whether  the  inner  or  outer  aspect  of 
the  thighs  is  more  thickly  covered.  Note  again 
the  remarkable  difference  between  the  front  and 
back  of  the  trunk,  and  reflect  that  the  back  is 
from  its  curve  more  exposed  than  the  front,  and 
does  in  fact  receive  constant  friction  from  the 
clothes;  note  how  the  shoulders  are  marked  by 
the  rash,  and  how  the  axilla  and  flank  are  spared, 
being  sheltered  by  the  shoulder  and  arm.     Then  the 


ch.vi]   THE   DISTRIBUTION   OF   THE   RASH         53 

upper  extremity ;  examine  the  fingers  ;  count  the 
spots  on  the  backs  of  the  fingers,  and  the  spots 
between  them,  and  compare  the  numbers.  Count 
the  spots  on  the  forearm  and  those  on  the 
arm,  compare  them  and  consider  whether  the 
figures  point  accurately  to  the  degree  of  irritation  ; 
examine  whether  the  extensor  or  flexor  aspect  of 
the  forearm  is  most  thickly  covered,  and  similarly 
examine  the  outer  and  inner  surfaces  of  the  arm. 

Coming  to  the  face,  see  how  free  from  rash  is  the 
depression  round  the  eye  and  how  favoured  the 
nose  and  the  sides  of  it ;  and  generally  speaking 
how  the  rash  picks  out  the  hard  and  prominent 
parts  and  avoids  those  that  are  soft  and  sheltered. 
See  how  a  sharp  line  marks  off  the  exposed  portion 
of  the  neck  where  it  begins  to  be  protected  by 
the  clothes.  That  brings  us  to  an  explanation 
of  the  hands  and  face  being  the  normal  sites  of 
election.  What  parts  are  more  exposed  than 
they  to  irritation  of  wind  and  weather  ? 

Such,  shortly,  is  the  thesis  which  Dr.  Bicketts 
worked  out,  for  fuller  details  of  which  his  book* 
should  be  consulted. 

*  The  "Diagnosis  of  Smallpox,"  by  T.  F.  Ricketts,  M.D. 
Illustrated  from  photographs  by  J.  B.  Byles,  M.B.  pp.  154.  122 
Illustrations.     Cassell  &  Co.     21s. 


54  HOW   TO   DIAGNOSE   SMALLPOX      [ch.  vi 

Nothing  is  so  useful  in  diagnosis  as  the 
phenomena  of  the  distribution  of  the  rash.  It 
should  be  understood,  however,  that  the  method 
requires  practice,  and  should  be  used  with  discrimi- 
nation. Special  attention  must  be  paid  to  the 
habits  of  the  individual  patient  under  considera- 
tion, and  to  the  conditions  to  which  the  skin  is 
exposed.  Where,  for  instance,  would  you  expect 
to  find  the  greatest  incidence  of  rash  on  an  ill-kept 
infant  ?  What  differences  in  distribution  and 
intensity  would  you  expect  to  find  between  the 
rashes  of  a  clerk  and  a  sailor  ?  What  differences 
again  between  the  winner  of  a  London  to  Brighton 
walking  race  and  an  old  bedridden  woman  ? 


Plate  I 


SMALLPOX. 


Plate  II 


SMALLPOX. 


Plate  III 


SMALLPOX. 


Plate  IV 


SM  \I.I.|M.\. 


CHAPTER   VII 

OTHER   FACTORS    IN    DIAGNOSIS 

We  now  come  to  some  other  characters  of  small- 
pox, which  have  a  bearing  on  diagnosis.  Dr. 
Ricketts  has  called  attention  to  the  dual  nature 
of  the  disease ;  and  the  observation  is  just.  He 
considers  smallpox  to  be  a  two-fold  disease,  in  this 
way.  Smallpox  proper  is  limited  to  the  stage  of 
invasion,  and  when  the  first  period  of  fever  is 
over,  the  attack  proper  is  past.  The  so-called 
secondary  fever,  caused  by  the  suppuration  of 
the  rash,  is  in  the  nature  of  an  appendix  to 
the  attack,  much  in  the  same  way  that  nervous 
phenomena  may  follow  influenza,  or  broncho- 
pneumonia may  follow  measles.  It  does  not  follow 
that  in  every  case,  once  the  fever  proper  is  over, 
there  is  any  rise  of  temperature  at  all.  It  may 
happen  that  the  rash  is  too  scanty,  or  that  it 
rapidly    aborts.     I    mention   this,   partly   because 


56  HOW   TO  DIAGNOSE   SMALLPOX      [ch.vii 

it  meets  a  point  of  difficulty  which  is  sometimes 
raised.  "  It  couldn't  have  been  smallpox,"  it  is 
said,  "  the  temperature  was  normal  throughout." 
Very  possibly,  once  the  attack  proper  has  passed 
off.  Of  course,  an  observed  normal  temperature 
throughout  a  supposed  onset  would  negative 
smallpox ;  but  in  a  mild  attack  the  temperature 
may  soon  fall  to  normal,  before  the  scanty  rash 
has  been  observed,  and  so  escape  notice.  Mild 
cases  therefore  require  close  observation.  The 
following  is  an  illustration. 

A  Salvation  Army  captain,  who  was  stationed 
at  the  door  of  a  Shelter  during  an  epidemic,  to 
observe  men's  faces,  and  to  endeavour  to  keep 
out  any  cases  of  smallpox,  was  taken  with  a  bad 
cold,  with  influenza,  according  to  his  own  account, 
and  soon  felt  nearly  well  again.  "  What  you  want 
now,"  his  senior  officer  said  to  him,  "  is  a  day  or 
two  off  duty,  and  a  breath  of  fresh  air  to  pull 
you  together  after  your  influenza,  so  away  you 
go."  He  went  off  to  a  watering-place  on  the 
South  Coast.  During  his  stay  there  he  went  for 
a  steamboat  trip  round  the  Isle  of  Wight,  he 
said,  and  they  had  got  round  to  the  back  of  the 
Island,  when  he  noticed  he  had  a  few  spots  on 


ch.  vn]      OTHER    FACTORS   IN    DIAGNOSIS  57 

his  face.  He  returned  that  day  and  showed 
himself  to  the  doctor.  It  was  smallpox,  and  the 
man  finished  his  holiday  on  the  river,  instead  of 
at  the  sea.  From  the  time  of  his  going  away 
on  leave  he  was  not  at  all  ill,  had  no  fever,  ate 
and  slept  well.  Mild  cases  of  this  kind  are  very 
apt  to  escape  notice,  principally  from  the  patient 
becoming  and  remaining  perfectly  well  when  the 
initial  fever  has  gone. 

There  is  one  characteristic  feature  of  smallpox 
which  may  be  of  material  assistance  in  diagnosis. 
In  any  well-marked  attack  there  is  a  severe 
prostration  accompanying  the  fever  of  the  onset, 
and  dominating  the  case  before  and  when  the 
rash  is  first  making  its  appearance.  Milder  forms 
of  smallpox  resemble  influenza  in  this  respect. 
The  patient  is  rendered  prostrate.  If  he  can 
keep  to  his  work,  the  attack  must  be  unusually 
mild  or  the  patient  unusually  determined.  Com- 
monly he  is  confined  to  the  house.  He  sits  by  the 
fire  or  keeps  his  bed.  He  tells  you  he  is  so  weak 
in  the  knees  that  he  cannot  stand ;  his  legs  give 
way  under  him.  He  does  not  want  to  speak, 
move,  or  eat.  He  wants  to  be  left  alone.  There 
is  a  marked  relaxation  of  muscular  tone.     In  the 


58  HOW   TO   DIAGNOSE   SMALLPOX      [ch.  vn 

index  afforded  by  the  delicate  muscles  of  the 
face,  the  loss  of  tone  is  evidenced  by  a  charac- 
teristic expression.  It  has  been  compared  to  that 
of  a  man  who  has  had  a  hard  run  for  a  train,  has 
just  caught  it,  and  sunk  down  exhausted  into  a 
seat.  There  is  apt  to  be  a  similar  facial  ex- 
pression of  prostration  and  relaxation  in  the  early 
stages  of  smallpox. 

I  have  a  note  of  the  onset  of  smallpox  in  a  girl 
of  about  three  years  of  age,  whom  I  saw  not  long 
ago.  The  rash  was  just  appearing.  The  note  runs  : 
"  the  natural  muscular  tension  is  absent ;  she  looks 
exceedingly  tired;  there  is  a  pallor  and  a  sug- 
gestion of  ashy  greyness  in  the  face,  and  an 
expression,  when  her  attention  is  roused  for  a 
moment,  which  is  both  appealing  and  hope- 
less." This  child  had  a  severe  attack,  and 
died. 

I  may  illustrate  this  characteristic  prostration  in 
another  way,  namely,  by  showing  the  importance 
of  its  absence.  I  was  asked  to  see  a  girl  of  twelve. 
She  had  a  rash  which  was  due  either  to  small- 
pox or  chickenpox.  Whatever  it  was,  it  was 
very  copious,  being  especially  thick  on  hands  and 
forearms  and  on  legs  and  feet.     It  was  one  of  the 


ch.  vn]     OTHER    FACTORS   IN   DIAGNOSIS  59 

most  puzzling  rashes  that  could  be  imagined. 
Neither  the  distribution  nor  the  elements  of  the 
rash  gave  much  help.  But  reliable  evidence 
showed  that  she  and  her  family  had  been  to  a 
fair  on  a  Bank  Holiday,  and  from  it  had  walked 
home  several  miles,  three  I  think,  at  the  close 
of  the  day.  On  the  next  day  the  rash  came 
out.  The  outing  and  long  walk  at  the  time  of 
invasion  were  strong  evidence  against  the  attack 
being  smallpox  ;  for  the  prostration  which  must 
have  accompanied  an  attack  of  smallpox  so  severe 
as  to  produce  such  a  copious  rash,  would  have 
rendered  impossible  so  much  muscular  exertion 
as  had  in  fact  been  taken  by  the  child.  The 
diagnosis  of  chickenpox  was  made.  Her  sister 
who  had  been  successfully  vaccinated  about  a 
year  previously,  was  infected  by  her,  and  had 
a  similar  attack  of  chickenpox. 

One  other  matter  may  be  mentioned  in  this 
place.  It  is  useful  to  have  in  a  handy  form 
the  dates  of  a  moderately  severe  attack  of 
smallpox,  by  way  of  having  a  typical  case  for 
reference.  The  different  stages  may  be  noted  in 
this  way.  Suppose  a  man  who  has  smallpox 
comes   home   from   abroad   on  New  Year's   Day, 


60  HOW  TO   DIAGNOSE   SMALLPOX     [ch.  vn 

and  on  that  day  infects  his  brother.     The  brother's 
illness  and  rash  will  be  dated  as  follows  : 


Exposure  to  infection 

Onset  of  fever 

Rash  papular — day  1  to  3     . 

„     vesicular — day  3  to  5  . 

,,      pustular — day  5  to  9    . 

„     drying— day  9  to  17    . 


Jan.  1st. 

Jan.  13th. 

Jan.  15th  to  Jan.  17th. 

Jan.  17th  to  Jan.  19th. 

Jan.  19th  to  Jan.  23rd. 

Jan.  23rd  to  Jan.  31st. 


Beyond  this,  it  is  necessary  to  allow  a  further 
period,  before  all  the  seeds  can  be  removed 
from  the  palms  and  soles.  Though  smallpox 
presents  extraordinary  varieties  of  type  and  all 
degrees  of  severity,  and  though  it  may  be 
difficult  to  fix  upon  an  average  case,  it  is  never- 
theless useful  in  practice  to  have  some  such  case 
to  refer  to  and  work  by,  to  use  as  a  type  to 
which  other  cases  can  be  referred.  The  incubation 
period  of  smallpox  is  remarkably  constant,  twelve 
days  being  the  general  rule. 

In  the  case  taken  as  a  type,  it  will  be  noted 
that  two  days  are  allotted  to  the  papular  stage, 
and  two  days  to  the  vesicular  ;  four  days  to  the 
pustular,  and  eight  days  to  the  drying  stage,  the 
stadium  exsiccationis.  In  practice,  it  is  found 
convenient  to  speak  of  the  stage  of  a  case  by  the 
date  of  the  rash.     It  is  possible  to  make  a  close 


ch.  vii]        OTHER  FACTORS  IN  DIAGNOSIS  61 

and  even  accurate  estimate  of  the  day  when  the 
rash  appeared,  by  observing  the  stage  of  the  rash  as 
it  comes  under  observation.  When  patients  con- 
ceal the  true  story,  a  not  infrequent  occurrence,  the 
medical  attendant  may  be  able  to  form  his  own 
opinion  of  the  day  on  which  they  actually  fell  ill. 
Such  estimates  are  often  most  useful  in  tracing 
the  history  of  an  outbreak  of  the  disease. 


CHAPTER  VIII 


DIFFERENTIAL   DIAGNOSIS 

Having  thus  reviewed  some  of  the  more  striking 
characters  of  smallpox  itself,  we  pass  to  compare 
it  with  other  diseases  with  which  it  has  been  con- 
fused, and  to  consider  how  it  may  be  differentiated 
from  them. 

In  the  year  1902,  7842  was  the  total  number  of 
cases  which  were  certified  in  London  as  smallpox 
and  sent  to  the  Receiving  Stations.  607  of  these 
cases  were  found  not  to  be  smallpox,  and  were 
classified  as  shown  in  the  following  list : — 


Number  of  cases. 

Number  of  cases. 

1.  Chickenpox         

203 

Cases  carried  forward 

..  314 

2.  Measles 

48 

14.  Bronchitis 

..       2 

8.  Syphilis    ... 

30 

15.  Uraemia... 

1 

4.  Scarlet  Fever       

4 

16.  Appendicitis 

5.  German  Measles 

7 

17-  Pericarditis 

G.  Influenza 

3 

18.  Bright' s  disease 

1 

7.  Typhoid  Fever     

2 

19.  Pyaemia 

8.  Pulmonary  Tuberculosis 

2 

20.  Acute  Mania 

9.  Erysipelas            

3 

21.  Delirium  tremens 

10.  Meningitis           

2 

22.  Cerebral  Tumour 

11.  Pneumonia           

3 

23.  Traumatic  Mastitis 

1 

12.  Rheumatism        

2 

24.  Septicaemia 

13.  Febris,  unclassified 

5 

25.  Purpura 

2 

ch.  vni]         DIFFERENTIAL   DIAGNOSIS 


63 


Number  of  cases. 

Cases  carried  forward  ...  328 

26.  Acne        

27.  Erythema  Rheumaticum 

28.  Erythema  Iris 

29.  Urticaria 

30.  Eczema 

31.  Impetigo 

32.  Lichen 

33.  Herpes 

34.  Sycosis 

35.  Chloasma 

36.  Psoriasis 

37.  Drug  Rashes 

38.  Pemphigus 


Number  of  caBes. 

Cases  carried  forward  ...  471 

42  39.  Lupus  Erythematosus  ... 

13  40.  Furunculosis      

2  41.  Dermatitis  due  to  bites 

12  of  insects        

31  42.  Scabies 

4  43.  Whitlow  

26  44.  Vaccination  Rashes 

4  45.  Horsepox  

1  46.  Skin  Diseases,  unclassi- 

1  lied      

2  47  Lumbago 

3  48.  No  ascertainable  disease 
2  Total         


1 

2 

7 

11 

1 

o 
O 

1 

74 

1 

35 

607 


For  the  purpose  of  differential  diagnosis,  it  is 
best  to  consider  these  various  diseases  in  groups. 
Following  the  clinical  course  of  smallpox,  we  will 
begin  with  those  diseases  which  may  simulate  it 
before  any  rash  appears  at  all ;  pass  then  to  the 
stages  of  the  initial  rashes  of  early  hemorrhagic 
smallpox,  and  of  the  rash  proper ;  in  this  way  we 
shall  see  what  diseases  have  been  confused  with  the 
various  stages  of  smallpox,  and  why.  A  number 
of  points  that  bear  on  diagnosis  will  thus  come 
naturally  into  view. 

First  of  all,  let  us  take  rather  a  strange  group, 
viz.,  lumbago,  rheumatism,  and  appendicitis. 
Nothing  that  could  be  said  about  the  pains 
of     smallpox    is    so     eloquent    as     this    strange 


64  HOW  TO   DIAGNOSE   SMALLPOX     [ch.  vm 

list.       It    is    not    difficult    to    understand    how 
lumbago    may    be    thought    to  be  smallpox,   but 
rheumatism   and    appendicitis    do    not    obviously 
resemble  it.     Pain  in  the  back  is  a  feature  of  small- 
pox, of  which  it  is  often  difficult  to  appraise  the 
value   correctly.      There   are  cases,  of  course,   in 
which  it  is  a  sharply  cut  feature,  as  in  the  case  of 
the  little  girl  mentioned  on  page  58.     With  her  it 
outweighed  everything  else.    In  reply  to  a  question 
as  to  what  was  the  matter,  "  Oh,  it's  my  back  ! "  she 
said  in  a  pitiful  low  voice,  and  pointed  there.     The 
pain  may  be  so  excruciatingly  severe  as  to  require 
morphia.     In  other  cases  it  is  ill  defined,  varying 
in  position  and  severity,  and  it  may  be  even  absent. 
It  may  be  emphatically  said  that  the  statement 
"  no  pain  in  the  back  "  does  not  exclude  smallpox. 
Among    the    cases    listed    above    which     turned 
out    not    to  be    smallpox,   "pain    in    the    back" 
was  present  again  and   again ;  and  it  seemed   to 
have  been  responsible  for  mis-diagnosis  on  a  good 
many   occasions.       Especially   was   it   apt    to    be 
valueless   in   women,   as   might   be   supposed,   on 
account  of  its   frequent  association  with   uterine 
disorder.      It    is  also    apt    to   be   of    little   value 
in    those    who    admit    chronic   ill-health     before 


ch.  viii]         DIFFERENTIAL   DIAGNOSIS  65 

the  rash  could  have  supervened.  In  persons  who 
"  always  suffer  with  my  back "  or  "  have  been 
aching  for  the  past  week"  it  is  very  difficult  to 
say  where  a  chronic  backache  ends  and  one  due 
to  smallpox  begins.  In  such  cases  pain  in  the 
back  is  best  discarded  from  consideration.  In 
a  previously  healthy  child  or  man,  on  the  other 
hand,  it  may  be  a  clear  and  very  striking  feature. 
But  it  is  always  a  subjective  sign,  and  must  be 
treated  with  the  reserve  which  that  class  of 
evidence  requires. 

The  belief  that  the  pain  due  to  smallpox  seldom 
or  never  occurs  in  other  parts  of  the  body  than 
the  back  is  not  at  all  in  accordance  with  the  facts. 
For  instance,  I  recollect  a  case  of  acute  illness 
being  taken  into  a  general  hospital,  and,  on 
account  of  the  character  of  the  pains,  considered 
to  be  acute  rheumatism.  The  correct  diagnosis, 
namely,  smallpox,  was  made  by  observing  the 
progress  of  the  case  and  the  appearance  of  the  rash 
that  supervened. 

It  may  seem  remarkable  that  what  was  really 
appendicitis  should  have  simulated  smallpox  ;  the 
converse  also  occasionally  happens.  The  confusion 
is  due  to  the  backache  of  smallpox  radiating  round 

F 


66  HOW  TO   DIAGNOSE   SMALLPOX     [ch.  viii 

the  trunk  and  manifesting  itself  in  the  front  as  well 
as  in  the  back.  It  is  important  to  realise  this  : 
otherwise  it  might  be  thought  that  abdominal 
pain  excludes  smallpox  ;  it  does  not. 

Dr.    A.   F.    Cameron,   who    has    given    close 
attention   to   this   symptom  as   observed  in  7000 
cases  of  smallpox,  wrote  as  follows  in  his  Thesis  on 
"  The  factors  on  which  diagnosis  in  smallpox   is 
based,"  Edinburgh,  1903.    "  The  occurrence  of  pain 
in  the  back  seems  to  have  received  a  position  of 
undue  importance.      Certainly   severe  lumbar  or 
lumbosacral    pain    does   not    occur  with  the  in- 
variability on  which  so  much  stress  is  laid.     Even 
in    trustworthy    patients    presenting     attacks    of 
moderate   severity,   in   which  the  lesions  at  full 
development  may  number  between  one  and  two 
hundred    on    the    face,   the   backache   may  have 
been   so   slight   that  it   is  quite   forgotten.     The 
situation   of    this  pain  seems    as   variable  as  its 
severity.     Often   it  is  felt  in  the   dorsal   region. 
Many    affirm    that    all    the    pain    they    suffered 
was  in  the  neck  and  amounted  to  no  more  than 
a   slight   stiffness.     On  the   other  hand,  some  in 
whom  the   onset  is  exceedingly  severe  refer  the 
pain   entirely   to  the   front   of  the   body.     Some 


ch.  vin]  DIFFERENTIAL  DIAGNOSIS  67 

describe  it  as  a  sense  of  tightness  or  suffocation 
in  the  chest,  others  as  severe  abdominal  pain 
which  they  mistake  for  colic.  In  the  latter  the 
flinching  caused  by  superficial  palpation  and  the 
aggravation  of  the  pain  on  deep  inspiration  and 
sudden  movement,  seems  to  indicate  that  it  is 
really  referred  to  the  abdominal  wall,  deep 
palpation  producing  no  increase  either  in  resis- 
tance or  discomfort."  The  fact  is  that  the  initial 
pains  of  smallpox  often  have  a  wider  distribution 
than  is  usually  supposed ;  the  localised  back  pain 
in  the  lumbar  region  is  commonest,  but  in  other 
parts  pains  are  not  uncommon,  and  must  on  no 
account  be  considered  to  be  inconsistent  with 
smallpox. 

The  next  group  of  the  above  list  comprises 
certain  other  acute  diseases  which  are  not  usually 
marked  by  a  rash.  They  are  influenza,  meningitis, 
pneumonia,  pericarditis,  and  unclassified  cases  of 
"febris."  The  onset  of  smallpox  often  differs 
little  from  that  of  other  acute  diseases  attended 
by  fever,  as  for  instance  pneumonia.  Lumbar 
pain,  vomiting,  and  prostration  may  mark  out  some 
cases  of  smallpox ;  but  often  there  is  no 
distinguishing    mark,  and    no   certainty  until  the 


68  HOW    TO   DIAGNOSE   SMALLPOX    [ch.  viii 

rash  appears ;  diagnosis  may  have  to  be  left  till 
then.  Influenza  claims  a  word.  It  is  seldom  mis- 
taken for  smallpox ;  but  conversely,  it  fairly  often 
happens  that  what  is  really  smallpox  is  believed 
to  be  influenza.  A  diagnosis  of  "  influenza  with 
spots"  is  very  suggestive  of  variola,  and  often 
requires  further  inquiry.  In  fact,  an  attack  of 
smallpox  of  slight  or  even  moderate  degree  may 
bear  at  first  a  very  close  resemblance  to  an  attack 
of  influenza.  Especially  are  both  marked  by 
prostration ;  and  the  remarks  on  page  57  about 
that  symptom  are  worthy  of  close  attention. 

Next  we  come  to  another  group  of  rashless 
diseases,  of  a  kind  which  seem  to  have  not  the 
remotest  resemblance  to  smallpox.  They  are 
pulmonary  tuberculosis,  bronchitis,  acute  mania, 
cerebral  tumour,  mastitis,  and  thirty-six  cases  of 
no  ascertainable  disease.  In  all,  the  total  number 
of  cases  listed  here,  and  presenting  no  rash,  is 
sixty-one.  It  is  easy  to  explain  how  the  majority 
of  these  came  to  a  Receiving  Station  as  smallpox. 
They  were  "long  shots."  I  recall,  for  instance, 
the  arrival  of  an  ambulance  omnibus  which  brought 
six  patients  fully  dressed.  Among  them  was  one 
case  of  smallpox;    a  second   developed   the  rash 


ch.  vm]         DIFFERENTIAL  DIAGNOSIS  69 

of  smallpox  next  day.  The  third  had  acute 
pneumonia ;  and  the  other  three  had  nothing  the 
matter  with  them.  Other  cases  in  this  category 
were  such  as  had  some  trifling  disorder,  children, 
for  instance,  who  had  eaten  too  many  sweets, 
in  whose  house  or  street  there  had  been  cases 
of  smallpox.  Most  of  these  patients  were  simply 
contacts,  and  no  useful  purpose  was  served  by 
certifying  them  as  smallpox  and  sending  them 
to  the  Receiving  Station.  Little  is  usually  gained 
by  certifying  a  patient  whose  skin  is  perfectly 
clear,  and  the  patient  is  apt  to  incur  a  good 
deal  of  annoyance  and  some  risk.  A  rash  should 
always  be  awaited.  To  postpone  certification  till 
the  appearance  of  the  rash  is  a  good  working  rule. 

In  looking  for  an  early  rash,  it  is  well  to 
remember  how  slight  it  may  appear.  One  is 
often  struck  with  its  insignificant  and  even  benign 
appearance,  when  it  first  begins  to  show.  I 
remember  a  woman,  whose  disease  was  really 
smallpox,  and  whose  rash  was  exactly  like  that 
of  enteric  fever.  It  was  composed  of  rose 
papules  on  the  abdomen.  They  were  soft  and 
inconspicuous.  The  rash  came  first  on  the  upper 
part   of  the  abdomen,  where   there  was   pressure 


70  HOW  TO   DIAGNOSE    SMALLPOX    [ch.  vni 

and  irritation  from  the  clothes.  After  twelve 
hours  or  so,  the  eruption  became  general,  and  ran 
a  normal  course. 

Even  in  a  severe  case,  the  early  papular  rash 
may  have  no  disagreeable  aspect  at  all.  The 
face  and  other  parts  of  the  skin  may  be  thickly 
marked  with  it  without  being  much  disfigured  or 
rendered  especially  conspicuous.  Patients  them- 
selves may  think  at  first  that,  after  all,  small- 
pox is  not  so  terrible  as  it  was  made  out  to 
be.  They  are  comparatively  easy  after  the  abate- 
ment of  the  initial  pain  and  malaise,  and  may 
even  be  really  comfortable.  At  first  the  facial  out- 
lines and  expression  may  be  not  greatly  changed. 
But  the  rash  develops  inexorably.  Nothing  is 
more  striking  than  the  contrast  between  the  appear- 
ance of  a  face  on  the  first  day  of  a  severe  rash 
and  that  on  the  octave.  By  that  time  each  tiny, 
innocent-looking  pink  spot  has  gradually  swelled 
to  many  times  its  original  size,  to  a  foul  abscess, 
with  which  its  crowding  fellows  have  run  together, 
so  that  the  face  is  puffed  up  into  a  huge,  coarse- 
looking  mask,  which  is  completely  unrecognisable. 

On  what  part  of  the  skin  ought  we  to  search 
for  the  oncoming  rash  ?     The  forehead  and  roots  of 


ch.  vin]  DIFFERENTIAL  DIAGNOSIS  71 

the  hair  should  be  well  looked  over  ;  any  part  of 
the  face  that  is   already  sore  is  a  favourite  early 
site,  such  as  the  nostrils  when  chafed  with  coryza; 
or  the  muco-cutaneous  junction  of  the  lips.     The 
prominences  of  the  cheek  bones  and  the  sides  of 
the  nose  should  be  examined.     No  search  is  con- 
clusive unless  it  is  made  in  a  good  light.     Atten- 
tion  should   be    given   to   the  wrists,   hands  and 
forearms.     A  little  observation  and    inquiry    will 
show   whether  any  particular   part  of  the  skin  is 
specially  irritated,  such  as  the  feet  of  a  tramp,  the 
groins  of  a  baby,  the  site  of  recent  vaccination,  or 
any  recent  sore,  scratch,  or  burn. 

An  important  region  is  the  buccal  cavity,  for 
the  earliest  indications  of  rash  may  be  found  here. 
A  patient  may  draw  attention  to  soreness  of  the 
throat  or  the  feeling  of  spots  inside  the  lips.  A 
careful  look  at  the  pharynx  may  show  superficial 
erosions  into  which  the  vesicles  will  have  been 
macerated  almost  as  soon  as  they  were  formed. 
Their  appearance  may  not  be  sufficient  to  dis- 
tinguish smallpox  from  chickenpox,  but  they  will 
almost  certainly  indicate  the  presence  of  one  of 
these  two  conditions. 


CHAPTER  IX 

THE    INITIAL   RASHES 

Next  let  us  take  two  groups  of  diseases  which 
may  simulate  the  initial  rashes  of  smallpox.  In 
the  one  we  have  purpura  of  various  kinds,  and  in 
the  other  measles,  scarlet  fever,  rotheln,  urticaria, 
and  erythema.  These  two  groups  typify  the  two 
classes  of  smallpox  initial  rash,  each  of  which 
has  distinct  characteristics.  There  should  be  no 
difficulty  in  getting  a  thorough  grasp  of  them. 
The  one  class  is  petechial,  persistent,  and  sinister ; 
the  other  is  erythematous,  fugitive,  and  benign. 

Let  us  first  take  the  petechial.  This  class 
possesses  a  strong  individuality  among  rashes 
generally.  When  once  its  acquaintance  is  made, 
it  is  easily  recognised  again.  To  begin  with,  it 
has  a  strong  individuality  in  the  matter  of 
position;  it  always  occurs  in  the  groins;  it 
may  occur  elsewhere,  but  always  in  the  groins. 


ch.  ix]  THE   INITIAL   RASHES  73 

See  the  diagrams  at  the  end  of  the  chapter.     It  is 
sometimes   called    the   bathing  drawers  rash,  but 
that  description  is  not  accurate.     It  is  essentially 
a  rash  of  the  flexures  of  the  groin.     If  you   ink 
the  fold  of  the  groin,  and  strongly  flex  the  thigh 
on  to  the  abdomen,  the  surface  of  the  skin  then 
stained   gives   a   fair  approximation  of  the   usual 
distribution   of  this   rash.     It  occupies  just  those 
parts   of  the   skin   which   are   in   contact   in   full 
flexion.     Inferiorly,  it   is   sharply   bounded   by   a 
line  running  across  the  thigh  parallel  to  Poupart's 
ligament,  between  two  and  three  fingers'  breadth 
below  it.     On  the   surface  of  the  abdomen   it  is 
less  sharply  defined;   there  it  has  a  tendency  to 
be    lighter  and    more    scattered  ;    its   margin    is 
indefinite  and  spreads  upwards  towards  the  axilla. 
It  nearly  always  occurs  in  both  groins;    and  its 
extensions  on  the   abdomen   are   apt  to   meet  in 
front,   and    more   rarely   to   pass   round    towards 
or  to  the  small  of  the  back.     It  often  marks  the 
axilla ;  leaving  free  the  hairy  part,  indeed  all  the 
pit  of  the  axilla,  and    marking   out   the  anterior 
and  posterior    folds.      It   may   lightly  affect   the 
back  of  the  neck  and  of  the  knees.      But   it  is 
especially  a  rash  of  the  groins. 


74  HOW  TO   DIAGNOSE   SMALLPOX       [ch.  ix 

As  to  its  quality  and  colour.  At  the  time 
when  it  is  usually  first  seen,  that  is,  when 
attention  has  been  drawn  to  it  by  the  appear- 
ance of  the  papular  rash,  it  is  petechial  and  has 
a  stippled  appearance.  By  the  second  day  of  the 
true  rash,  the  groin  may  look  exactly  as  if  it  had 
been  splashed  or  stippled  with  rusty  orange  and 
rusty  red  ;  sometimes  these  colours  are  remarkably 
vivid.  From  this  time  it  gradually  fades ;  but 
traces  may  persist  until  the  fourth  or  fifth  day 
of  the  rash  proper. 

If  it  should  happen  to  be  seen  directly  it 
appears,  and  that  is  usually  on  the  second  day 
of  the  illness,  its  appearance  is  different.  Its 
distribution  is  the  same ;  but  it  is  then  a  dusky 
red,  rather  angry  looking,  uniform  sheet  of  colour. 
Part  of  this  can  be  discharged  from  the  skin 
by  pressure ;  part  cannot  be  discharged,  and  is 
petechial.  As  Dr.  A.  F.  Cameron  has  described 
it,  this  uniform  sheet  of  colour  resembles  the 
close  web  of  a  fabric ;  the  warp  of  which  is 
erythematous,  and  the  woof  petechial ;  the  erythe- 
matous warp  disappears  and  leaves  the  fading 
petechias  as  above  described. 

One  more  point  about  it.     It  always   has  a 


ch.  ix]  THE   INITIAL  RASHES  75 

sinister  import.  It  is  usually  associated  with  a 
severe  type  of  attack.  Not  that  such  an  attack  is 
always  fatal  or  even  dangerous.  But  prostration  is 
generally  marked,  and  the  initial  attack — the  attack 
proper — is  apt  to  be  severe. 

So  much  then  for  the  petechial  initial  rash; 
definite  in  locality,  persistent  in  point  of  duration, 
striking  in  appearance,  and  associated  with  severity. 
It  is  pathognomonic.  A  diagnosis  may  safely  be 
based  on  it. 

In  remarkable   contrast  to   this    is  the   other 

initial  rash,  the  characters  of  which  are   easy  to 

remember   as   being   almost    the  exact    opposites 

of  what   has   been   described.     Here   we    have  a 

transient,  fugitive  rash,  passing  in  a  few  hours  from 

one  part  of  the  skin  to  another  ;  it  is  superficial  and 

erythematous,  and  it  nearly  always  marks  a  mild 

attack.     This  erythema,  or  blush,  for  often  it  is 

hardly  more,  may  occur  on  the  limbs,  especially  the 

extensor  surfaces  of  the  arms,  and  spread  to  the 

trunk ;  or  may  first  show  itself  on  the  trunk  and 

spread  to  the  limbs.     It  is  apt  to  pass  quickly  from 

one  part  to  another,  in  the  course  of  a  few  hours, 

and  to   occupy  large  patches  and   areas   of  skin, 

leaving   other   parts   unaffected,   and   conspicuous 


76  HOW  TO  DIAGNOSE  SMALLPOX      [cat.  ix 

as  pale  islands  of  normal  surface.  It  soon  fades, 
and  in  the  process  may  pass  through  a  beautiful 
tint  of  colour,  a  somewhat  dusky,  delicate  shade  of 
pink ;  the  skin  of  the  shoulder  and  flank  and 
arm,  for  instance,  looking  as  if  it  might  have  been 
covered  by  an  excessively  thin  pink  film  from 
torn  places  in  which  the  edges  had  receded 
and  left  islands  of  a  natural  skin,  irregularly 
circular  in  outline.  By  this  time  the  rash 
proper  will  have  appeared,  in  the  form  of  papules 
few  and  far  between  ;  the  remaining  erythema  is 
grouped  around  them ;  it  soon  vanishes,  and  the 
papules  are  feeble  and  are  apt  to  abort. 

It  is  evident  that  this  rash  may  be  difficult 
to  identify,  and,  of  the  two,  is  the  less  likely  to  be 
useful.  But  in  some  instances  it  may  be  invaluable 
for  diagnosis.  I  recollect  more  than  one  case  in 
which  there  had  been  a  history  of  exposure  to 
infection,  and  there  was  in  due  time  a  rise  of 
temperature  and  onset  of  a  very  light  diffuse 
erythema,  and  of  superficial  rapidly  aborting 
papules,  less  than  ten  in  number. 

These  then  are  the  two  types  of  initial  rash, 
and  it  is  well  to  Hx  them  in  the  mind.  They 
have  variations.     The  most  noteworthy  are  those 


ch.  ix]  THE   INITIAL  RASHES  77 

in  which  the  initial  and  local  petechias  are  but 
precursors  of  petechias  which  develop  in  many 
other  situations  and  end  in  hasmorrhagic  smallpox 
and  death.  Of  the  benign  class  of  initial  rash 
there  are  varieties  in  which  the  rash  spreads  to  the 
face,  and  such  a  rash  may  be  slightly  but  definitely 
raised.  Occasionally  patients  present  the  appear- 
ance of  having  regular  types  of  the  two  initial 
rashes  at  the  same  time  in  the  same  individual. 

A  word  must  be  said  about  the  difficulties 
presented  by  hemorrhagic  smallpox  when  accom- 
panied by  an  initial  erythema.  In  this  virulent 
type  of  the  disease  there  appears  simultaneously 
with,  or  very  soon  after  the  onset  (which  is  dis- 
tinguished by  its  violence),  an  erythema  which 
covers  the  whole  body,  involving  the  face  as  well 
as  the  trunk  and  extremities.  The  colour  of  this 
rash  is  usually  brilliant  at  first.  But  as  its 
brilliance  fades  to  a  purplish  colour,  the  skin 
becomes  studded  with  petechia?.  Soon  the  larger 
haemorrhages  make  their  appearance  and  by  their 
size,  their  colour,  and  their  number,  stamp  the 
case  unmistakably  as  one  of  smallpox.  Such 
cases  occur,  but  happily  are  not  common.  One 
precaution  may  be  suggested.     If  a  case  is  met 


78  HOW  TO   DIAGNOSE   SMALLPOX      [ch.  ix 

with  in  which  a  violent  onset  of  fever  is  accom- 
panied or  soon  followed  by  the  appearance  of  a 
generalised  erythema,  affecting  the  face  and  not 
showing  very  definite  punctuation,  smallpox  must 
be  carefully  considered,  and  excluded,  before  the 
case  is  labelled  as  one  of  scarlet  fever.  The  whole 
skin  surface  must  be  carefully  scrutinised.  The 
careful  observer  may  be  rewarded  by  the  dis- 
covery of  a  few  flat  vesicular  lesions,  i.e.  the 
true  rash,  widely  scattered  over  trunk  and 
extremities.  The  presence  of  such  lesions  with 
a  dominant  purpura  forms  not  merely  an 
additional  ground  of  suspicion ;  it  clinches  the 
diagnosis  of  smallpox. 

Generally  speaking,  as  to  the  distinction  between 
scarlet  fever  and  smallpox,  confusion  can  only 
occur  in  the  absence  of  the  papular  rash  of  small- 
pox, and  in  the  presence  of  the  initial  ones.  It 
is  very  desirable  therefore  to  study  the  account 
which  has  just  been  given  of  the  initial  rashes. 
When  such  rashes  are  present,  there  must  be 
sought  the  other  features  of  smallpox,  a  sharply 
oncoming  fever  of  short  duration  marked  by 
vomiting  and  prostration  and  pains.  On  the  other 
hand,  the  well-known  features  of  scarlet  fever  must 


ch.  ix]  THE   INITIAL   RASHES  79 

also  be  looked  for ;  the  punctate  character  of 
the  rash,  often  seen  to  the  best  advantage  on 
the  flank  and  inner  aspect  of  the  thigh ;  the 
inflamed  fauces;  the  characteristic  tongue  and 
glands. 

Measles  and  rotheln  come  next  to  be  con- 
sidered. Measles  is  more  fully  spoken  of  on 
p.  93,  where  it  is  contrasted  with  the  papular 
rash  of  smallpox.  That  is  the  kind  of  smallpox 
rash  with  which  it  is  commonly  confused.  It  is 
less  often  confused  with  an  initial  rash  of  small- 
pox. I  do  not  recall  having  seen  an  initial  rash 
of  smallpox  which  bore  a  marked  degree  of 
resemblance  to  an  ordinary  measles  rash.  Any 
doubtful  case  should  be  studied  in  the  light  of 
what  has  been  said  about  initial  rashes  to  see 
if  it  conforms  at  all  to  smallpox  ;  and  then  to  see  if 
it  conforms  at  all  to  either  measles  or  rotheln. 
The  initial  erythema  of  smallpox  comes  on  the 
second  day  of  illness,  not  on  the  face,  or  very 
rarely  so,  and  is  widely  diffused  in  a  few  hours; 
measles  appears  on  the  face  and  is  marked  by 
a  gradual  spread  over  the  whole  surface  of  the 
body.  Rotheln  is  marked  by  a  lightness  of 
symptoms,   which   is  rare  in   smallpox.     Both   it 


80  HOW   TO   DIAGNOSE   SMALLPOX       [ch.  ix 

and  measles  are  commonly  distinguished,  on  the 
trunk,  by  an  approximate  evenness  of  pattern  of 
the  rash.  In  smallpox,  the  rash  is  symmetrical, 
in  point  of  its  general  distribution  on  the  trunk 
and  limbs,  but  the  spots  on  any  given  area  are 
not  so  evenly  distributed.  But  it  may  be  that  only 
the  development  or  non-development  of  the  rash 
proper  of  smallpox  will  settle  the  diagnosis  :  and 
such  an  issue  may  have  to  be  awaited. 

Urticaria  may  cause  difficulty,  but  I  recollect 
having  seen  only  one  initial  variolous  rash  that 
was  raised  and  was  suggestive  of  urticaria. 

Erythemata  and  drug  rashes  of  various  kinds 
are  also  to  be  considered.  Injection  of  an  anti- 
toxin serum  may  certainly  produce  a  rash  not 
at  all  unlike  an  initial  erythema  of  smallpox ;  so 
may  some  food  poisons  ;  careful  inquiry  should 
be  made  whether  any  drugs  or  noxious  articles 
of  diet  have  been  recently  taken ;  self-prescribed 
sleeping  draughts  and  powders,  and  patent 
medicines,  such  as  the  antipyretics,  should  also 
be  kept  in  mind  as  possibilities. 

Next  we  come  to  a  difficult  group  of  the 
rashes  which  simulate  smallpox,  namely,  purpura 
of    various    forms,    especially    such    as    may    be 


ch.ix]  THE   INITIAL   RASHES  81 

associated  with  ulcerative  endocarditis,  meningitis, 
and  septicaemia.  A  great  number  of  smallpox 
cases  present  petechias  at  some  time  in  their  course. 
No  severe  attack  of  smallpox  occurs  without  them. 
But  what  we  have  to  think  of  here  is  purpura 
without  any  papular  rash. 

Bug  bites,  and  especially  flea  bites,  in  a  feverish 
subject  may  raise  a  suspicion  of  smallpox,  which, 
in  a  dirty  subject,  is  not  at  all  unreasonable. 
But  marks  of  this  kind  have  an  appearance 
characteristic  of  their  origin,  and  soon  tend  to  fade 
when  the  patient  has  been  cleansed  and  freed  of 
vermin.  But  a  warning  is  desirable.  Smallpox 
occurring  among  the  dirty  and  neglectful  may 
cause  a  patient's  skin  to  present,  side  by  side,  both 
the  haemorrhages  of  smallpox  and  those  due  to 
insect  bites  as  well ;  and  there  is  a  risk  that  the 
latter  may  be  recognised  aright,  but  the  whole 
rash  attributed  to  them.  Some  of  the  most 
puzzling  rashes  that  occur  are  due  to  the  super- 
vention of  smallpox  on  previously  existing  skin 
disorder. 

Anyone  who  is  called  to  see  a  patient  showing 
petechia?,  the  cause  of  which  is  doubtful,  should 
make  a  special  point  of  asking  himself  the  question 

G 


82  HOW  TO   DIAGNOSE   SMALLPOX      [ch.  ix 

whether  smallpox  could  produce  them.  If  the 
disease  is  suspected,  the  flexures  should  especially 
be  examined.  Not  .a  few  cases  of  hemorrhagic 
smallpox  are  but  extensions,  so  to  speak,  of  the 
petechial  initial  rash  already  described.  Should  a 
rash,  however,  exhibit  petechia?  which  have  not 
this  peculiar  distribution,  and  yet  suggest  small- 
pox, every  part  of  the  skin  must  be  carefully 
examined.  In  smallpox  the  conjunctivae  are 
marked  sooner  or  later  by  haemorrhages,  blood- 
red  in  colour  ;  the  eyelids  by  extravasations  which 
are  bluish-black.  The  face,  neck,  shoulders,  front 
and  back  of  the  trunk,  and  all  the  limbs  must  be 
carefully  examined,  special  attention  being  paid 
to  the  flexures  and  to  the  points  of  pressure,  and 
a  general  view  should  be  taken  of  as  much  of  the 
surface  as  can  be  seen  at  once.  Haemorrhages,  if 
due  to  smallpox,  usually  vary  in  size,  shape  and 
colour.  Evenness  in  these  respects  suggests  some 
other  disorder.  In  a  case  which  I  recently  saw, 
for  instance,  haemorrhages  were  numerous  and 
smallpox  had  been  feared,  but  the  lesions  were 
even  in  size,  even  and  circular  in  outline,  even  in 
relative  distance,  and  they  were  all  of  one  variety. 
These  points  were  against  smallpox.     That  disease 


ch.  ix]  THE   INITIAL  RASHES  83 

was  excluded  in  favour  of  ulcerative  endocarditis  ; 
and  the  diagnosis  confirmed  by  the  post-mortem 
examination. 

Haemorrhages  in  smallpox  fall  usually  into  one 
of  three  varieties.  They  may  be  red  or  reddish- 
purple  petechias ;  or  they  may  be  as  dark  as 
inkspots,  as  Dr.  MacCombie  describes  them  ;  or 
they  may  have  the  appearance  of  bruises.  The 
last-named  will  be  found  at  points  of  pressure  or 
handling,  which  in  hemorrhagic  smallpox  is  very 
prone  to  produce  haemorrhages  of  this  class. 
Careful  examination  must  be  made  of  the  mucous 
tracts.  The  tongue  and  buccal  cavity  require 
close  attention,  and  their  examination  gives  an 
opportunity  for  testing  the  smell  of  the  breath. 
In  not  a  few  hemorrhagic  cases  it  has  a  sickly 
and  peculiar  odour,  otherwise  indescribable,  similar 
to  that  noticeable  in  some  cases  of  haematemesis. 
Special  inquiry  should  be  made  to  ascertain  if 
blood  is  escaping  from  any  of  the  mucous  orifices. 

In  connection  with  hemorrhagic  smallpox 
generally,  one  or  two  other  points  are  worth 
attention.  Not  seldom  the  back  pain  is  very 
severe,  excruciatingly  so,  and  that  of  itself  may 
suggest  this    class   of   attack.      Another    feature 


84*  HOW   TO   DIAGNOSE   SMALLPOX      [gh.  ix 

which  may  form  a  useful  clue  is  the  respiration. 
It  is  always  quickened. 

Not  infrequently  there  is  a  low  range  of  tem- 
perature, such  as  about  101°  or  100°.  The  patient 
may  be  remarkably  quiet ;  once  the  first  pain  is 
over  there  may  be  no  apparent  distress,  no  high 
temperature,  no  bounding  pulse,  apparently  nothing 
fulminant.  There  may  even  be  complete  mental 
composure  and  even  alertness.  "  Very  chatty " 
is  the  bedside  note  on  diagram  IV.  A  patient  may 
read  his  newspaper  with  interest,  and  discuss 
his  plans  for  the  future,  all  the  while  looking 
about  him  with  the  very  stamp  of  death  upon 
his  face,  and  quite  unconscious  of  it.  But  he 
is  certain  to  die  soon,  and,  it  may  be,  very 
quietly  and  unexpectedly. 


S+nsii 


I>i.UiH.\M   I.  -Petechial  iuitial  rash  of  smallpox  dotted  in  on  diagram,  with  bedside  notes. 


r&l*    Out's  k*trK\ 


\J 


\ 


initial  rash  of  smallpox  d< 


w 


Diagram  II.— Petechial  initial  rash  of  smallpox  dotted  in  on  diagram,  with  bedside  notes. 


*/«{» 


6/ 


C*  A*    ^ 


/t 


\       I 


/ .  '*,■?■¥. 


Diagram  III.— Petechial  initial  rash  of  smallpox  dotted  in  on  diagram,  with  bedside  notes.     Hasuiorrhagio  smallpox  Bupervenod, 


^X^JUvw-, 


7K~        n- 


*— '-Y* 


&r  • 


IV. — Dusky  erythema 


i  z 


'7X0.  .  f^LdV^ 


nu  *~^  */**»"- (*-**>*«  '"" 


Diagram  IV.— Dusky  erythema  and  hemorrhagic!  smallp 


CHAPTER  X 

DIFFERENTIAL   DIAGNOSIS   OF    CHICKENPOX   AND    OF 

MEASLES 

Our  attention  is  now  claimed  by  the  differential 
diagnosis  of  diseases  which  are  apt  to  be  confused 
with  the  rash  of  smallpox  in  its  papular  stage 
or  later;  and  first  comes  chickenpox.  From  the 
list  on  pp.  62-3,  it  is  seen  that,  of  the  total  607, 
no  less  than  203,  that  is  one-third,  were  chicken- 
pox.  This  disease  therefore  requires  special  con- 
sideration. 

In  the  differential  diagnosis  of  smallpox  and 
chickenpox  it  is  usual  to  take  the  history 
first  and  then  to  examine  the  elements  of  the 
rash  ;  and  to  leave  the  distribution  to  the  last. 
The  fallacies  of  histories  have  been  pointed  out 
on  pp.  29  to  34 ;  such  an  example  of  chickenpox 
diagnosed  upon  history,  as  is  there  given,  is  by 
no  means  uncommon.     To  get  correct  results,  it 


86  HOW   TO   DIAGNOSE   SMALLPOX        [ch.  x 

is  necessary  to  take  the  rash  first,  and  carefully 
to  consider  its  distribution. 

The  distribution  in  chickenpox  cases  is  striking, 
and  significant.  On  the  face  the  rash  is  well 
marked,  and  on  the  chest  it  is  the  same,  and 
so  it  usually  is  on  the  back.  But  on  the  ex- 
tremities it  fades  away  from  above  downwards, 
till  on  the  hands  and  feet  there  is  hardly  any 
at  all.  This  gradual  decrease  in  the  rash,  as 
one  passes  from  the  shoulders  to  the  hand,  is  a 
strong  characteristic  of  chickenpox ;  and,  more- 
over, is  in  marked  contrast  to  smallpox.  When- 
ever a  diagnosis  is  to  be  made  between  chickenpox 
and  smallpox,  it  is  a  very  practical  step  to  have 
the  patient  stripped  to  the  waist,  and  seated  in  a 
good  light  with  the  arms  crossed  in  front,  as  in 
the  man's  photograph  at  the  end  of  this  chapter. 
Often  this  posture  by  itself  will  demonstrate  the 
diagnosis  without  any  further  evidence.  No 
opinion,  however,  should  be  given  without  a  com- 
plete examination. 

The  distribution  should  be  carefully  observed, 
stress  being  laid  upon  the  relative  density  of  the 
rash.  In  the  photograph  of  the  man  alluded  to, 
the  density  of  the  rash   on   the  chest,  compared 


ch.  x]  DIAGNOSIS   OF  CHICKENPOX  87 

with  that  of  the  rash  on  the  face,  is  more  com- 
patible with  chickenpox  than  smallpox  ;  that  is 
to  say  it  is  too  thick  on  the  chest,  relatively, 
for  smallpox.  And  when  the  freedom  from 
blemish  of  the  arms  and  hands  is  considered  with 
reference  to  the  density  on  the  chest  and  face, 
that  relative  distribution  of  the  rash  puts  small- 
pox out  of  court.  It  is  necessary  to  emphasize 
the  word  relative;  it  is  the  proportion  of  the 
spots  in  one  area  to  those  in  another  that  is  all 
important. 

The  same  comparison  between  the  face,  side, 
arm,  and  hand  may  be  made  in  the  case  of  the 
girl's  photograph,  resulting  in  the  same  diagnosis. 
That  such  a  case  is  not  smallpox  may  be 
perceived  from  the  mere  arrangement  of  the 
spots. 

This  much  should  be  added,  however,  about  the 
distribution  of  the  chickenpox  rash.  Occasionally 
it  also  shows  a  tendency  to  favour  sore  or  irritated 
surfaces.  I  have  seen  chickenpox  rash  pick  out 
scratches  and  burns  ;  and,  in  infants'  skins,  surfaces 
irritated  by  rubbing.  Only  the  tendency  for 
chickenpox  to  favour  these  sites  is  very  much  less 
than  in  the  case  of  smallpox. 


88  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  x 

Let  us  now  take  the  individual  lesions  of  the 
two  diseases  and  compare  them.  Take  the 
vesicular  stage  of  smallpox.  In  the  first  place, 
many  of  the  lesions  are  circular  in  outline; 
those  that  are  not  so,  are  but  slightly  out  of 
the  circular  and  some  that  at  first  sight  looked 
elliptical,  are  seen  on  closer  examination  only  to 
have  that  form  from  the  fusion  of  two  circular 
lesions.  Nearly  all  the  pocks  are  tense,  and  have 
a  firm  and  definite  outline  ;  and  finally,  they  are 
all  definitely  set  in  the  skin  and  not  on  it.  In 
order  to  appreciate  the  depth  at  which  the  lesion 
is  set,  roll  a  loose  fold  of  skin  between  finger 
and  thumb ;  a  method  which  applies  more 
especially  when  lesions  are  in  the  papular  stage. 
It  is,  of  course,  an  important  point  of  differentia- 
tion, this  degree  of  depth  in  the  skin  at  which 
the  lesions  are  situated.  It  is  of  no  use  to  feel 
spots  against  a  bony  surface;  when  so  felt,  spots 
on  the  face  are  often  shotty. 

Now  look  at  the  characteristics  of  the  chicken- 
pox  rash.  Choose  anywhere  but  the  face  if  you 
can,  for  the  purpose  of  examining  the  elements 
of  the  rash.  The  rash  on  the  face,  both  of 
smallpox   and    chickenpox,   is    less   easy  to    read 


ch.  x]  DIAGNOSIS   OF  CHICKENPOX  89 

than  on  other  parts  of  the  body;  so  the  face  is 
best  left  till  the  last.  Many  cases  occur  in  which 
the  rash  on  the  face  is  puzzling,  but  unmistakable 
in  other  regions.  This  is  notably  the  case  with 
chickenpox  in  adults.  The  rash  of  chickenpox 
on  the  face  of  an  adult  is  apt  to  be  coarse  and 
obscured,  and  may  resemble  that  of  smallpox  on 
the  same  region,  much  more  closely  than  does  a 
smallpox  rash  in  the  flank  resemble  chickenpox 
in  this  situation.  Therefore,  rather  avoid  the  rash 
on  the  face,  not  in  considering  the  distribution, 
of  course,  but  in  considering  the  elements  of  which 
the  rash  is  composed. 

Look  now  at  the  individual  lesions  of  chicken- 
pox  on  the  trunk,  in  such  a  part  as  the  small  of 
the  back,  or  the  flank,  or  the  neighbourhood  of 
the  umbilicus,  or  the  anterior  fold  of  the  axilla, 
and  see  what  the  pock  is  like.  Often  it  is  not 
circular,  but  is  elliptical,  lozenge  or  spindle- 
shaped,  the  long  axis  lying  in  the  same  direction 
as  do  the  natural  folds  of  the  skin  on  which  the 
spot  lies.  That  is  a  point  worth  bearing  in  mind. 
Next,  the  outline  of  the  vesicle  is  not,  as  a  rule, 
sharp  and  firm  and  well-defined,  but  is  irregular  and 
crenated.     This  goes  with  the  general  appearance 


90  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  x 

of  the  vesicle,  which  commonly  does  not  look 
tumid  and  tense  and  bursting  with  pressure  from 
within ;  often  the  pellicle  is  wrinkled  and  flaccid 
and  even  fallen  in;  so  that  a  kind  of  spurious 
umbilication  may  be  present.  All  these  features 
of  the  chickenpox  lesion  are  in  association  with, 
and  are  caused  by,  the  superficial  position  of  the 
spots  in  the  skin.  If  a  piece  of  the  affected  skin 
be  lightly  pinched  up  and  rolled  between  the 
fingers,  this  superficial  position  will  at  once  be 
evident. 

Though  these  various  characters  are  often  of 
material  assistance  in  distinguishing  chickenpox, 
they  may  be  insufficient  for  that  purpose;  for 
the  elements  of  the  one  disease  may  resemble 
the  elements  of  the  other  with  marvellous  close- 
ness. Generally  speaking,  the  resemblances  between 
smallpox  and  chickenpox  are  very  remarkable ;  so 
much  so  as  to  suggest  they  are  descended  from  ' 
a  common  ancestor.  In  adults  at  least,  both  are 
marked  by  sudden  onset,  by  fever  and  the 
symptoms  commonly  associated  therewith ;  on 
the  third  day,  a  rash  appears  which  runs  a  course 
from  papule  through  vesicle,  pustule,  scab  and 
scar.     I  recall  three  children  of  the  same  family 


ch.  x]  DIAGNOSIS   OF   CHICKENPOX  91 

who  were  admitted  together,  and  presented  rashes 
which  were  very  remarkable.  All  the  attacks 
were  mild  and  discreet.  One  of  the  patients  might 
have  been  thought  to  have  had  both  chicken- 
pox  and  smallpox  at  one  and  the  same  time — a 
phenomenon  which  I  have  never  seen.  Another 
frankly  had  smallpox.  But  the  third  had  a  rash 
which  was  a  marvellous  counterfeit  of  chickenpox, 
in  almost  every  particular.  The  pocks  seemed 
superficial  and  were  free  from  any  surrounding 
redness;  they  were  unilocular,  translucent,  pearly 
little  blisters,  a  "window"  of  which  was  almost 
impossible  to  distinguish  from  chickenpox.  The 
lapse  of  twenty-four  hours,  however,  displayed 
the  rash  in  its  true  character,  deeper,  more 
robust,  redder,  and  angrier.  It  is  in  such  cases 
that  we  are  driven  to  consider  what  else  there 
may  be  which  may  differentiate  the  major  from 
the  minor  disease.  Unilocation  will  not  help  us. 
Nor  is  it  of  much  practical  assistance  that  chicken- 
pox  may  come  out  in  crops.  In  any  given  window 
of  the  skin,  chickenpox  may  show  lesions  in  every 
variety  of  stage,  namely  as  papule,  vesicle,  pustule, 
scab.  This  is  in  part  due  to  the  difference  in  size 
of  individual  lesions.     The  small  ones  run  a  shorter 


92  HOW  TO   DIAGNOSE   SMALLPOX        [ch.  x 

course  than  the  larger ;  and  this  partly  accounts 
for  the  irregularity  of  the  rash.  A  similar  phe- 
nomenon is  often  seen  in  smallpox,  though  not 
to  so  marked  a  degree.  No  one  should  think 
of  smallpox  as  a  rash  composed  of  elements 
of  perfectly  even  size.  That  is  seldom  the 
case.  Nor  again  are  the  spots  evenly  or 
regularly  dotted  about  as  if  each  were  the 
centre  of  many  regular  squares  or  circles — that 
is  never  so. 

It  is  sometimes  suggested  that  if  lesions  ap- 
pear upon  the  mucous  membranes  of  the  mouth, 
that  fact  excludes  chickenpox.  But  the  rash 
of  chickenpox  appears  in  those  situations  too. 
Nor  is  there  any  difference  between  the  two 
diseases,  so  far  as  I  am  aware,  in  their  relative 
incidence  on  the  hard  and  soft  palates,  as  has 
sometimes  been  alleged.  A  heavy  incidence  of 
rash  on  hands  and  feet  is,  by  itself,  an  argument 
against  chickenpox,  but  it  requires  to  be  supported 
by  other  evidence :  I  have  seen  not  a  few  cases 
of  chickenpox  in  which  there  was  abundant  rash 
on  the  extremities. 

The   conclusion    is    that    there   is    no    single 
touchstone  for  the  differentiation  of  smallpox  and 


ch.  x]  DIAGNOSIS  OF  MEASLES  93 

chickenpox.  Stress  has  already  been  laid  on  the 
preference  of  the  rash  of  smallpox  for  irritated  and 
exposed  surfaces,  and  no  doubt  that  is  the  most 
useful  single  point  of  difference  between  it  and 
many  other  diseases,  chickenpox  included.  But  it 
is  imperative  to  take  the  whole  of  the  evidence  and 
weigh  it  together. 

Passing  now  to  measles,  which  comes  next  on 
the   list,  we   find   that   clinicians  who   have   seen 
little  smallpox   are   apt    to    think    they  are    not 
likely  to  confuse   smallpox  with   measles ;   and  I 
think  they  are  right.     It  is  those  who  are  fairly 
conversant   with   smallpox   who    are    more   likely 
to  be  mistaken.      That   is   one  of  the  subtleties 
of  smallpox.      It   by  no   means   follows    that   an 
observer  who   has   seen   some   hundreds  of  cases 
for   diagnosis,  and   has   got  a  good  grasp  of  the 
subject, — it    by   no    means   follows    that   he   will 
have  no   further   difficulties   or   pitfalls   to   avoid. 
On    the    contrary,    traps    will    be    provided    for 
him  at  every  stage  of  proficiency;   and   measles 
is  more   apt  to   puzzle   the   skilled   than   the  in- 
experienced. 

Let   me  give   an   illustration.      I  was  with   a 
practitioner   who     had    recently   left   a    smallpox 


94,  HOW  TO   DIAGNOSE   SMALLPOX       [ch.  x 

hospital    and    entered    general    practice;    he    re- 
peatedly  called    my   attention    to    the    close    re- 
semblance  between    some    cases   of    measles    we 
saw  together  and  the  smallpox  cases  with  which 
he  had  previously  been  familiar.     He  repeatedly 
remarked    how    alike    they    looked    at    the    first 
glance.     It   is   in    fact   the   case.     Measles,   when 
full  out  on  the  face,  may  bear  an  extraordinarily 
close  resemblance  to  a  smart  attack  of  smallpox 
about  the  second  day  of  the  rash.     I   saw   such 
a    case    recently.      The    patient    was    an    adult ; 
when   I  went  into   the   room   and   saw   the  face 
thickly   covered   with    rash    looking  at   me   over 
the  top  of  the  sheets,  smallpox  involuntarily  came 
into  mind.     At  the  first  glance  one  could  hardly 
doubt  the  rash   was   due   to   smallpox,   and    the 
apprehensions  of  my  colleague  with  whom  I  was 
in  consultation,  seemed  fully  justified.     Not  only 
was   the   rash   plainly  raised  to   sight  and  touch, 
but   in   the   circumoral    region,    especially   at   the 
right  side  of  the  lower  lip,  it  felt  tough  and  firm, 
and  was  slightly  but  plainly  vesicular.     Moreover 
the  history  was  consistent.     There  was  a  two  days' 
history  of  fever   and   its   usual   accompaniments; 
there  had  been  pains,  and  there  was  prostration. 


ch.  x]  DIAGNOSIS  OF  MEASLES  95 

The  patient  looked  and  was  most  seriously  ill. 
But  the  temperature  was  105° ;  and  that  was  a 
point  against  smallpox  at  the  end  of  the  papular 
stage.  More  important,  however,  was  the  distri- 
bution of  the  r&sh,  I  would  repeat  the  warning, 
given  on  p.  89,  to  beware  of  paying  too  much 
attention  to  the  elements  of  a  rash  on  the  face. 
I  had  the  patient  undressed  to  the  waist.  On 
an  inspection  of  the  trunk,  the  true  nature  of 
the  rash  became  at  once  evident.  If  one  had 
seen  it  first  on  the  pectoral  region  or  on  the 
back,  and  had  not  seen  the  face,  one  could  not 
have  doubted,  for  a  moment,  that  it  was  due  to 
measles.  Its  density  on  the  chest,  the  peculiar 
outline  of  its  elements,  the  comparative  regularity 
of  its  pattern,  the  absence  of  any  definite  papules 
— this  with  other  points  about  its  distribution 
generally,  excluded  smallpox,  and  settled  the 
diagnosis  of  measles.  I  had  an  opportunity  of 
seeing  the  case  again  at  the  end  of  twenty-four 
hours;  by  that  time  the  rash  had  almost  left 
the  face.  The  skin  was  almost  normal.  Far 
otherwise  would  it  have  been  in  a  case  of  small- 
pox ;  a  rash  due  to  that  disease,  however  soft  and 
velvety  it   might  have   been   even  on  the  second 


96  HOW  TO   DIAGNOSE  SMALLPOX        [ch.  x 

day,  would  have  become  so  aggressive  and 
determined  and  enlarged,  at  the  end  of  twenty- 
four  or  forty-eight  hours,  as  to  be  impossible  of 
mistake. 


Plate  V 


Photo  by  Dr.  J.  Howell  Griffiths.] 


CHICKENPOX. 


Plate  VI 


Photo  by  Dr.  J.  Howell  Griffith*.] 


CHICKENPOX. 


CHAPTER  XI 

ADDITIONAL    POINTS 

Generally  speaking,  when  smallpox  is  suspected, 
the  most  useful  plan  is  to  ask  the  question  of 
yourself,  Can  smallpox  produce  this  ?  Then  ex- 
amine the  various  areas  in  turn  from  the  point  of 
view  of  distribution,  and  proceed  to  examine  the 
elements  of  which  the  rash  is  composed. 

In  this  connection  I  may  draw  attention  again 
to  a  point  mentioned  on  page  28.  It  is  that  a 
well  marked  rash  cannot  be  due  to  smallpox,  if  the 
skin  of  a  whole  limb  or  other  extensive  area  be 
entirely  free  of  rash.  Take,  for  instance,  the  rashes 
mentioned  in  the  above  list  as  due  to  bites  of 
insects.  Several  of  these  were  due  to  bug  bites. 
The  favourite  seat  was  the  neck,  with  some 
extension  on  to  the  shoulder  and  back  ;  but  the 
rest  of  the  skin  of  the  body  was  perfectly  clear ; 
and  that  absolutely  excluded   smallpox.     In   this 

H 


98  HOW   TO    DIAGNOSE   SMALLPOX      [ch.  xi 

same  class  were  several  cases  due  to  mosquito 
bites.  Two  of  these  patients  were  English  persons 
who  had  been  badly  mosquito-bitten  in  Holland. 
The  forearm,  wrist,  and  hand  of  one  of  them 
bore  a  remarkable  resemblance  to  those  of  a 
patient  attacked  by  smallpox ;  indeed,  the  rash 
was  almost  indistinguishable.  Moreover,  the  face 
was  similarly  affected,  the  bites  having  been 
inflicted  while  the  patients  were  asleep  in  bed. 
Now  here  were  two  patients  whose  rashes  were 
conspicuous  on  the  hands  and  face,  and  regarded 
cursorily,  had  the  closest  resemblance  to  smallpox, 
and  were  certified  to  have  that  disease ;  but 
examination  showed  the  rest  of  the  skin  to  be 
absolutely  free  from  any  blemish  whatever.  That 
put  the  diagnosis  of  smallpox  absolutely  out  of 
court.  However  much  the  local  rash  resembles 
smallpox,  if  it  is  at  all  copious  and  if  it  is 
strictly  local,  and  the  rest  of  the  skin  is  clear,  it 
cannot  be  smallpox.  Smallpox  is  a  generalised 
disease  and  exhibits  something  like  a  general 
symmetry  in  distribution. 

There  are  one  or  two  additional  points  which 
may  usefully  be  mentioned. 

It  is  well  to  know  how  to  identify  the  latest 


ch.  xi]  ADDITIONAL  POINTS  99 

stage  of  smallpox,  that  is,  after  most  of  the 
scabs  have  disappeared.  In  inquiring  into  an 
outbreak  it  is  not  uncommon  to  receive  a  history 
of  some  one  having  fallen  ill  several  weeks 
previously;  and  the  suspicion  of  smallpox  is 
raised.  A  complete  and  careful  examination 
of  the  skin  is  required.  Such  an  examination 
may  establish  an  attack  of  smallpox,  even  where 
the  rash  has  been  light.  A  foot  bath  must 
be  used  if  the  feet  are  not  perfectly  clean ; 
for  on  their  condition  the  diagnosis  may  turn. 
On  the  face,  what  may  appear  at  first  sight 
to  be  large  papules,  are  on  careful  examination 
seen  to  be  nodules  of  scar  tissue.  Similar 
but  less  prominent  lesions  may  be  seen  on  the 
hands.  If,  in  addition  to  these,  pigmented  recent 
scars  are  seen  scattered  about  the  trunk  and 
other  areas  (and  the  tenderer  the  skin,  as  a 
rule,  the  flatter  and  softer  the  scar),  and  if  on 
a  general  review  the  distribution  corresponds 
with  that  of  smallpox,  then  it  may  with  confidence 
be  said  that  smallpox  could  have  caused  these 
lesions.  A  very  careful  inspection  should  be 
made  of  the  palms  of  the  hands  and  soles  of  the 
feet   and   toes,  for   in   these   situations  the   scabs 


100  HOW   TO   DIAGNOSE   SMALLPOX      [ch.  xi 

are  apt  to  remain  longest.  If  in  such  situations, 
deeply  situated  brown  scabs  can  be  seen  through 
the  horny  epidermis  and  partly  masked  by  it, 
the  diagnosis  can  be  clinched.  Only  it  should 
be  remembered  that  scabs  under  the  thick  skin  do 
not,  of  themselves,  denote  smallpox :  occasionally 
chickenpox  produces  them.  The  distribution  of 
the  scars  and  scabs  must  be  consistent  with  that 
of  the  rash  of  smallpox. 

The  assistance  which  may  be  gained,  in  obscure 
cases,  from  watching  the  progress  and  development 
of  the  rash  should  not  be  overlooked.  There 
were  sent  for  admission,  for  instance,  a  number 
of  patients,  several  of  whom  had  a  chronic  skin 
disorder ;  from  some  of  them  smallpox  could 
be  excluded,  but  of  one  other  the  skin  was 
already  so  thickly  covered  by  a  chronic  syphilide 
that  no  opinion  at  first  was  possible.  There  was 
nothing  to  be  done  but  watch  the  case;  in  the 
event,  hemorrhagic  smallpox  supervened,  but  so 
thick  was  the  chronic  rash  and  so  obscure  the 
acute  exanthem,  that  nothing  but  the  lapse  of 
time  and  the  development  of  the  rash  could 
have  rendered  the  diagnosis  certain.  The  slow 
development,  on  the  other  hand,  of  such  a  rash 


ch.  xi]  ADDITIONAL   POINTS  101 

as  is  due  to  bromide  or  iodide  of  potassium  may 
throw  valuable  light  on  its  diagnosis. 

Vaccination  is  a  factor  which  occasionally  may 
assist  diagnosis.  But  it  should  not  be  considered 
until  the  end  of  the  examination  proper.  Of 
course  recent  and  successful  vaccination  com- 
pletely excludes  smallpox.  But  it  may  not  be  easy 
to  say  when  vaccination  is  recent  and  successful. 
Mere  scars  may  be  of  little  value  in  this  connec- 
tion ;  and  statements  of  patients  that  the  operation 
was  recent  and  successful  are  to  be  received  with 
much  caution.  It  is  a  sound  administrative  rule  to 
regard  no  evidence  of  vaccination  as  satisfactory 
except  the  presence  of  a  pigmented  foveated 
scar.  Even  this  may  be  misleading,  if  revaccina- 
tion  has  been  unsuccessfully  performed  on  an  old 
scar. 

A  matter  which  should  always  be  in  the  mind 
of  the  diagnostician  is  the  environment  and  con- 
dition of  the  patient's  skin,  as  well  as  its  texture ; 
it  is  the  fineness  and  delicacy  of  the  skin  of 
children,  for  instance,  that  makes  a  smallpox  rash 
occasionally  appear  in  them  to  be  so  superficial.  In 
like  manner  the  rash  which  comes  on  the  flaccid, 
inelastic,   thin   and  partly   atrophied    skin   of   an 


102  HOW  TO   DIAGNOSE   SMALLPOX       [ch.  xi 

infirmary   bedridden   patient   has   a   character    all 
its  own. 

In  conclusion  my  advice  is  this.  Have  the 
possibility  of  smallpox  always  in  mind.  Have  the 
greatest  possible  respect  for  it.  Use  every  care 
in  examining  a  case.  Examine  the  whole  skin, 
and  see  it  in  good  light ;  do  not  be  satisfied  until 
you  have  so  seen  it.  Consider  the  distribution 
closely,  and,  if  necessary,  map  it  out  on  paper. 
Examine  in  what  degree  the  rash  is  superficial  or 
not.  Consider  the  history  last.  Weigh  all  the 
evidence  taken  altogether,  assigning  the  most 
importance  to  that  afforded  by  the  distribution 
of  the  rash. 


INDEX 


Acne,  39 

Action  brought  for  error  in  diag- 
nosis, 24 

Anomalous  smallpox  rashes,  48, 
49,50 

Appendicitis,  64,  65 

Backache,  31,  63  et  seq.,  84 
Blood-poisoning,   smallpox   diag- 
nosed as,  4,  8,  9 

Caledonia,  the  s.s. ,  5  et  seq. 
Chickenpox,  differential  diagnosis, 

85  et  seq. 
smallpox  diagnosed  as,  2,  3, 

5,  8,  9,  24,  32,  62 
Completeness  of  examination,  21, 

24 
Confluent  smallpox,  42 

Definition  of  smallpox,  44 
Depth  of  lesions  in  skin,  88 
Development  of  rash,  100 
Diagnosis  generally,  on  what  it 

depends,  15 
Diagrams,  usefulness  of,  27,  35 
Differential  diagnosis,  62  et  seq. 
Direct  evidence,  importance  of,  34 
Distribution  of  rash,  27,  28,  44, 

51  et  seq.,  86,  87 
of  smallpox  rash,   explana- 
tion of    underlying    principle, 
51  et  seq. 


Drug  rashes,  80 

Dual  nature  of  smallpox,  55 

Enteric  fever,  69 

Epidemics,  origin  of,  3,  4,  5,  10 

et  seq. 
Erythematous  initial  rash,  75 

Flat  type  of  rash,  41,  42 

Hsemorrhagic  smallpox,  6,  8,  77, 

82  et  seq. 
"  History,"  the,  31  et  seq. 

Influenza,  smallpox  diagnosed  as, 

3,68 
Initial  rashes,  72  et  seq. 

petechial,  73  et  seq. 

erythematous,  75 

signs  and  symptoms,  31,  32 

Irritated  surfaces,  45  et  seq. 

Late  stage  of  smallpox,  99 
Laundry,  smallpox  spread  by,  6, 

11 
List  of  other  diseases  diagnosed 

as  smallpox,  62 
Loculation,  42,  43,  91 

Measles,  differential  diagnosis  of, 
93 


104 


INDEX 


Measles,  smallpox  diagnosed  as,  3,  |  Salvation  Army  captain,  56 


4,  8,  62,  79 

Methods  of  examination,  19  et  seq. 
Metropolitan  Asylums  Board,  1, 

16  et  seq. 
Mosquito  bites,  39,  98 

Origin  of  smallpox  epidemics,  3, 
4,  5,  10  et  seq. 

Pain  in  the  back,  31,  63  et  seq., 

83 
Petechial  initial  rash,  73 
Prostration  in  smallpox,  32,  57 
Purpura,  80,  81 

Rash  of  smallpox,  anomalies  in, 
48,  49,  50 

on  mucous  membranes, 

71 

stages  of,  60 

Receiving  station,  17 

Relative  density  of  distribution, 

27,  28,  86,  87 
Rheumatism,  64,  65 
Rdtheln,  79 


Scarlet  fever,  78 

Shottiness  of  smallpox  rash,  39 
et  seq. 

Sites  of  early  smallpox  rash,  70 

Skin  texture,  101 

Smallpox  diagnosed  as  blood- 
poisoning,  4,  8,  9 

as  chickenpox,  2,  3,  5, 

8,  9,  24,  32,  62 

as  influenza,  3,  68 

as  measles,  3,  4, 8,  62,  79 

confluent,  42 

hemorrhagic,    6,    8,  77,  82 

et  seq. 

Spread  of  smallpox  by  unrecog- 
nised cases,  1  et  seq. 

Temperature  in  smallpox,  56,  84 
Typhoid  fever,  69 

Varicella.     See  Chickenpox. 
Vomiting,  32 

Umbilication,  37  et  seq. 


THE    END 


PRINTED  BY  WILLIAM  CLOWES  AND  SONS,  LIMITED,  LONDON  AND  BECCLES. 


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